Background

The utility of performing early myocardial revascularization among patients presenting with inducible myocardial ischemia and low left ventricular ejection fraction (LVEF) is currently unknown.

Objectives

In this study, we sought to assess the relationship between stress-induced myocardial ischemia, revascularization, and all-cause mortality (ACM) among patients with normal vs low LVEF.

Methods

We evaluated 43,443 patients undergoing stress-rest single-photon emission computed tomography myocardial perfusion imaging from 1998 to 2017. Median follow-up was 11.4 years. Myocardial ischemia was assessed for its interaction between early revascularization and mortality. A propensity score was used to adjust for nonrandomization to revascularization, followed by multivariable Cox modeling adjusted for the propensity score and clinical variables to predict ACM.

Results

The frequency of myocardial ischemia varied markedly according to LVEF and angina, ranging from 6.7% among patients with LVEF ≥55% and no typical angina to 64.0% among patients with LVEF <45% and typical angina (P < 0.001). Among 39,883 patients with LVEF ≥45%, early revascularization was associated with increased mortality risk among patients without ischemia and lower mortality risk among patients with severe (≥15%) ischemia (HR: 0.70; 95% CI: 0.52-0.95). Among 3,560 patients with LVEF <45%, revascularization was not associated with mortality benefit among patients with no or mild ischemia, and was associated with decreased mortality among patients with moderate (10%-14%) (HR: 0.67; 95% CI: 0.49-0.91) and severe (≥15%) (HR: 0.55; 95% CI: 0.38-0.80) ischemia.

Conclusions

Within this cohort, early myocardial revascularization was associated with a significant reduction in mortality among both patients with normal LVEF and severe inducible myocardial ischemia and patients with low LVEF and moderate or severe inducible myocardial ischemia.

中文翻译：

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基于诱导性缺血和左心室射血分数的早期血运重建的益处

背景

在出现可诱导心肌缺血和低左心室射血分数 (LVEF)的患者中进行早期心肌血运重建的效用目前尚不清楚。

目标

在这项研究中，我们试图评估正常与低 LVEF 患者的应激性心肌缺血、血运重建和全因死亡率 (ACM) 之间的关系。

方法

我们评估了从 1998 年到 2017 年接受应力静息单光子发射计算机断层扫描心肌灌注成像的 43,443 名患者。中位随访时间为 11.4 年。评估心肌缺血的早期血运重建与死亡率之间的相互作用。使用倾向评分调整非随机化至血运重建，然后使用针对倾向评分和临床变量调整的多变量 Cox 模型来预测 ACM。

结果

心肌缺血的频率因 LVEF 和心绞痛而显着不同，范围从 LVEF ≥ 55% 且无典型心绞痛的患者中的 6.7% 到 LVEF <45% 且具有典型心绞痛的患者中的 64.0% ( P  < 0.001)。在 39,883 名 LVEF ≥ 45% 的患者中，早期血运重建与无缺血患者死亡风险增加和严重 (≥15%) 缺血患者死亡风险降低相关（HR：0.70；95% CI：0.52-0.95）。在 3,560 名 LVEF <45% 的患者中，血运重建与无缺血或轻度缺血患者的死亡率获益无关，而与中度 (10%-14%) 患者的死亡率降低相关（HR：0.67；95% CI： 0.49-0.91) 和重度 (≥15%)（HR：0.55；95% CI：0.38-0.80）缺血。

结论

在这个队列中，早期心肌血运重建与正常 LVEF 和严重可诱导心肌缺血患者以及低 LVEF 和中度或重度可诱导心肌缺血患者的死亡率显着降低相关。