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Randomized Controlled Trial
. 2024 Jul 23;84(4):340-350.
doi: 10.1016/j.jacc.2024.04.043. Epub 2024 May 15.

Impact of Anatomical and Viability-Guided Completeness of Revascularization on Clinical Outcomes in Ischemic Cardiomyopathy

Saad M Ezad  1 , Margaret McEntegart  2 , Matthew Dodd  3 , Matthaios Didagelos  4 , Novalia Sidik  4 , Matthew Li Kam Wa  1 , Holly P Morgan  1 , Antonis Pavlidis  5 , Roshan Weerackody  6 , Simon J Walsh  7 , James C Spratt  8 , Julian Strange  9 , Peter Ludman  10 , Amedeo Chiribiri  11 , Tim Clayton  3 , Mark C Petrie  12 , Peter O'Kane  13 , Divaka Perera  14 ; REVIVED-BCIS2 Investigators
Collaborators, Affiliations
Randomized Controlled Trial

Impact of Anatomical and Viability-Guided Completeness of Revascularization on Clinical Outcomes in Ischemic Cardiomyopathy

Saad M Ezad et al. J Am Coll Cardiol. .

Abstract

Background: Complete revascularization of coronary artery disease has been linked to improved outcomes in patients with preserved left ventricular (LV) function.

Objectives: This study sought to identify the impact of complete revascularization in patients with severe LV dysfunction.

Methods: Patients enrolled in the REVIVED-BCIS2 (Revascularization for Ischemic Ventricular Dysfunction) trial were eligible if baseline/procedural angiograms and viability studies were available for analysis by independent core laboratories. Anatomical and viability-guided completeness of revascularization were measured by the coronary and myocardial revascularization indices (RIcoro and RImyo), respectively, where RIcoro = (change in British Cardiovascular Intervention Society Jeopardy score [BCIS-JS]) / (baseline BCIS-JS) and RImyo= (number of revascularized viable segments) / (number of viable segments supplied by diseased vessels). The percutaneous coronary intervention (PCI) group was classified as having complete or incomplete revascularization by median RIcoro and RImyo. The primary outcome was death or hospitalization for heart failure.

Results: Of 700 randomized patients, 670 were included. The baseline BCIS-JS and SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) scores were 8 (Q1-Q3: 6-10) and 22 (Q1-Q3: 15-29), respectively. In those patients assigned to PCI, median RIcoro and RImyo values were 67% and 85%, respectively. Compared with the group assigned to optimal medical therapy alone, there was no difference in the likelihood of the primary outcome in those patients receiving complete anatomical or viability-guided revascularization (HR: 0.90; 95% CI: 0.62-1.32; and HR: 0.95; 95% CI: 0.66-1.35, respectively). A sensitivity analysis by residual SYNTAX score showed no association with outcome.

Conclusions: In patients with severe LV dysfunction, neither complete anatomical nor viability-guided revascularization was associated with improved event-free survival compared with incomplete revascularization or treatment with medical therapy alone. (Revascularization for Ischemic Ventricular Dysfunction) [REVIVED-BCIS2]; NCT01920048).

Keywords: complete revascularization; heart failure; left ventricular dysfunction; percutaneous coronary intervention; stable coronary artery disease.

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Conflict of interest statement

Funding Support and Author Disclosures The trial was funded by the National Institute for Health and Care Research (UK) Health Technology Assessment Program (NIHR 10/57/67); and the present work was supported by the British Heart Foundation (FS/CRTF/21/24118, RE/18/2/34213 and RE/18/6/34217). The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Figures

Figure 1
Figure 1
Study Consolidated Standards of Reporting Trials (CONSORT) Diagram A total of 18 patients in the optimal medical therapy (OMT) arm had missing baseline angiography but were included in completeness of revascularization analyses because the revascularization index was assumed to be 0. CMR = cardiac magnetic resonance; FDG-PET = fluorodeoxyglucose positron emission tomography; PCI = percutaneous coronary intervention.
Figure 2
Figure 2
Anatomical Completeness of Revascularization vs OMT Kaplan-Meier plot of the primary outcome (death or hospitalization for heart failure [HHF]). The presented HRs for comparisons are adjusted. Incomplete anatomical revascularization (AR) vs optimal medical therapy (OMT): unadjusted HR: 1.13; 95% CI: 0.85-1.51; P = 0.40. Complete anatomical revascularization vs optimal medical therapy: unadjusted HR: 0.75; 95% CI: 0.54-1.06; P = 0.10.
Central Illustration
Central Illustration
Completeness of Revascularization in Revascularization for Ischemic Ventricular Dysfunction Core laboratory–analyzed coronary angiography and cardiac magnetic resonance were used to define anatomical and viability-guided completeness of revascularization. Primary and secondary outcomes are presented for those patients achieving complete revascularization vs optimal medical therapy (OMT). BCIS-JS = British Cardiovascular Intervention Society Jeopardy score; CV = cardiovascular; HF = heart failure; HHF = hospitalization for heart failure; LV = left ventricular; REVIVED-BCIS2 = Revascularization for Ischemic Ventricular Dysfunction; RIcoro = coronary revascularization index; RImyo = myocardial revascularization index; SYNTAX = Synergy Between PCI [Percutaneous Coronary Intervention] With Taxus and Cardiac Surgery.
Figure 3
Figure 3
Viability-Guided Completeness of Revascularization vs OMT Kaplan-Meier plot of the primary outcome (death or hospitalization for heart failure [HHF]). The presented HRs for comparisons are adjusted. Incomplete viability-guided revascularization (VGR) vs optimal medical therapy (OMT): unadjusted HR: 0.93; 95% CI: 0.67-1.30; P = 0.68. Complete viability-guided revascularization vs optimal medical therapy: unadjusted HR: 0.80; 95% CI: 0.56-1.13; P = 0.20.
Figure 4
Figure 4
Primary and Secondary Outcomes for Complete Revascularization Forest plot presenting the treatment effect of complete anatomical revascularization (AR) and viability-guided revascularization (VGR) on primary and prespecified secondary outcomes. CV = cardiovascular; HHF = hospitalization for heart failure; LV = left ventricular.
See this image and copyright information in PMC

References

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