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Canadian Journal of Cardiology

An Approach to the Rational Use of Revascularization in Heart Failure Patients

Published:November 18, 2013DOI:https://doi.org/10.1016/j.cjca.2013.11.012

      Abstract

      The most common cause of heart failure with reduced ejection fraction (HFrEF) is coronary artery disease. A multitude of factors come into play when deciding whether a patient with HFrEF and coronary artery disease should have coronary artery bypass graft (CABG) surgery, percutaneous coronary intervention, or medical therapy alone. For candidates for percutaneous coronary intervention and CABG, evidence from large registries would suggest that patients with 2-vessel coronary artery diseases and proximal left anterior descending disease and all patients with 3-vessel coronary artery disease do better with CABG. For patients that are candidates for medical therapy with or without CABG, the results of the Surgical Treatment for Ischemic Heart Failure (STICH) trial indicate that with CABG, the reduction of mortality is not statistically significant (hazard ratio [HR], 0.86; P = 0.12). However, CABG is superior in reducing cardiovascular deaths (HR, 0.81; P = 0.05), and the combination of cardiovascular deaths and cardiovascular hospitalizations (HR, 0.74; P < 0.001). Patients undergoing CABG have an upfront risk that is eliminated by 2 years and thereafter do better. The assessment of cardiac viability or reversible ischemia does not appear to be helpful in determining which individuals will improve more with CABG. Patients with severe mitral regurgitation who undergo CABG appear to benefit from simultaneous valve repair but not from the addition of surgical ventricular reconstruction of the left ventricle, although in specific patients this might be considered. The totality of evidence would thus suggest that patients with HFrEF should be evaluated for the possibility of coronary revascularization if they are candidates for CABG.

      Résumé

      La coronaropathie est la cause la plus fréquente de l’insuffisance cardiaque à fraction d’éjection réduite (ICFER). De nombreux facteurs entrent en jeu lorsque vient le temps de décider si un patient ayant une ICFER et une coronaropathie devrait subir un pontage aortocoronarien (PAC), une intervention coronarienne percutanée ou un traitement médical seul. Pour ce qui est des candidats à l’intervention coronarienne percutanée et au PAC, les données scientifiques provenant d’importants registres ont montré que les patients ayant des coronaropathies bitronculaires et une sténose de l’artère interventriculaire antérieure proximale, et que tous les patients ayant une coronaropathie tritronculaire bénéficieraient plus d’un PAC. Pour ce qui est des patients qui sont des candidats au traitement médical associé ou non au PAC, les résultats de l’étude STICH (Surgical Treatment for Ischemic Heart Failure) indiquent qu’avec le PAC la réduction de la mortalité n’est pas statistiquement significative (rapport de risque [RR], 0,86; P = 0,12). Cependant, le PAC est supérieur en ce qui a trait à la réduction des décès liés à la maladie cardiovasculaire (RR, 0,81; P = 0,05), et à la combinaison des décès et des hospitalisations liés à la maladie cardiovasculaire (HR, 0,74; P < 0,001). Les patients subissant un PAC ont un risque à court terme qui est éliminé au cours des 2 années subséquentes et s’améliorent par la suite. L’évaluation de la viabilité cardiaque ou de l’ischémie réversible n’apparaît pas utile pour déterminer les individus qui s’amélioreront le plus après un PAC. Les patients ayant une régurgitation mitrale grave qui subissent un PAC semblent bénéficier de la réparation valvulaire simultanée, mais non de la reconstruction chirurgicale du ventricule gauche, bien que cela puisse être envisagé chez certains patients. L’ensemble des données scientifiques montrerait donc que les patients ayant une ICFER devraient être évalués quant à la possibilité de revascularisation coronarienne s’ils sont candidats au PAC.
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