Coronary Artery Disease in Heart Failure : What We Have Learned and the Horizon
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Coronary Artery Disease in Heart Failure : What We Have Learned and the Horizon By Dr Han Naung Tun, MBBS, MD, FACC, FESC
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Coronary Artery Disease in Heart Failure : What We Have Learned and the Horizon
- 1. Coronary Artery Disease in Heart Failure : What We Have Learned and the Horizon Han Naung Tun MBBS, MD, FACTM, FACC, FESC UVM Medical Centre Larner College of Medicine , University of Vermont ,VT , USA @HanCardiomd
- 2. Conflict of Interest • Nothing to declare
- 3. Treatment Option for CAD in Chronic HF
- 4. Pros Vs Cons of CABG in Chronic HF
- 5. Can revascularization by CABG improve outcomes in Chronic HF ?
- 6. CABG for chronic HF
- 7. STICH – Inclusion and exclusion criteria
- 8. STICH – CV and All cause mortality
- 9. STICH – who benefits more ?
- 10. Effect of age on effect of CABG in STICH
- 11. STICH – Myocardial viability
- 12. Challenges of PCI in HF
- 13. Are CABG and PCI equal in HF ? RCTs of CABG Vs PCI in pts with HF Subgroup analyses of CABG Vs PCI trial Meta-analysis of CABG V PCI Trials : Subgroups with HF ?
- 14. Inclusion of patients with HF or LVSD in recent CABG Vs PCI Trials
- 15. What is the evidence for PCI Vs Medical Rx in HF ? No RCT of PCI Vs Med in HF Patient with HF excluded from large RCTs of PCI Vs Med (eg COURAGE excluded LVEF < 30 %)
- 16. The SHOCK Trial
- 17. The CULPRIT-SHOCK Trial NEJM 2017, 377 : 2419-32
- 18. Coronary Intervention for AHF
- 19. Trials that do not apply to AHF
- 20. ISCHEMIA trial patients with moderate LVSD (EF 35-45%, n=221) or HFpEF (n=177) had worse outcomes than those with normal LV. Excluded ACS within 2 months , Highly symptomatic patients , LM stenosis and LVEF <35% Signal of benefit with revascularisation in mLVSD/HFpEF, driven mainly by the small subgroup with HF symptoms.
- 21. Renato D. Lopes , et al. Circulation, Nov, 2020
- 22. Frequency of revascularization/Angiography in Acute HF
- 23. HF 2022 ACC/AHA/HFSA Guideline ESC 2021 HF Guideline
- 24. Revascularization For CAD in HFpEF : Still Controversial
- 25. Prevalence of CAD and CMD in HFpEF Rush CJ, et al. JAMA Cardiol. 2021
- 26. Impact of Revascularization on Survival in Patients With HFpEF With CAD Seok-Jae Hwang , JACC 2014
- 27. This nationwide study suggests that HFpEF with CAD undergoing CABG have comparable long- term survival to controls, and this is better than survival in HF patients with reduced EF undergoing CABG Salil V Deo , et al. EJHF Feb, 2022
- 28. Ongoing or planned RCT evaluating PCI in patient HF Yousif Ahmad, et al. JSCAI, 2022
- 29. The REVIVED Trial : PCI vs Med Rx in HF DivakaPerera ,et al. JACC 2018
- 30. Conclusion • Thinks about investigation for CAD in HF patients • If a patient has HF and younger , consider CABG if revascularization is needed . • To date, however, comparative data to establish the role of PCI compared with CABG in patients with HF are lacking. and but a lot of trials are ongoing to clarity the role of PCI in HF • Don’t forget to consider personalized approach
Editor's Notes
- Introduction, First of all, Thank you for invitation me to this young cardiologist meeting . I am …… ...
- -So, many patients with CAD do Angiogram, it is time for PCI, we do angiogram easily in many centers. Remarkedly in 2022, we have mounts of evidence, what to do, how to do , what not to do .
- In regards to CABG , You might think Bypass is good or not . It Take intensive care, need sternotomy, So, what is the balance So you know, The disadvantages of coronary bypass surgery is that it is a major surgery. And in that, that is a surgical trauma to the body, a cut if you will, one that it will take a few weeks to recover from.
- CASS is old trial, it is not HF trial , it is not answer for the question . when I was in internship life, I remember I was told by my older prof about this trial
- This is STICH Trial, some people like this trial. Some people don’t like it . Insightfully, we gained some important information from STICH
- In this study, a total of 1212 patients with an ejection fraction of 35% or less and coronary artery disease amenable to CABG were randomly assigned to medical therapy alone or medical therapy plus CABG , STICH excluded , LMCD and Angina CCS III and greater
- Here we see in this mortality benefit, the primary outcome of 5 yr , there is significantly no different . Basically, there is not different benefit at all in 2 years, Again, you can see it is positive or negative trial after 10 years. The rates of death from any cause, death from cardiovascular causes, and death from any cause or hospitalization for cardiovascular causes were significantly lower over 10 years among patients who underwent CABG in addition to receiving medical therapy than among those who received medical therapy alone
- So , again , you see it is also curial analysis , age on mortality benefits . , there are some more sub-Studies of STICH . More severe disease , more benefits . DM finding is interesting, most bypass surgery trial have DM, In STICH , Pts with or without DM received consistent benefits . And again, interestingly, pt with or without angina received consistent benefits as well .
- When we are talking about in term of age . although CABG benefit in CV mortality was cosistant across all ages , we noticed in older patient , it has less reduction in all cause mortality
- So now we are goanna talk about viability test, STCIH is the best data so far , it is RCT for which has viability test , not the best evidence of viability . But it is not perfect trial. Prior to STICH , there are several observational studies and some 2-3 meta-analysis showed a benefit for viability testing . You know, the viability sub study of STICH was a non-randomized observational analysis of 50 % of STICH pts who had viability with SPECT or Dobutamine stress echo . But STICH didn’t show benefits . As I was saying , we have no useful data on whether viability test helps or not .
- So, PCI in HF, we all know there are a lot of challenges in PCI for HF . Many CTO, many bifurcations, we may need LVADs in shock or end stage HF . We need to think which one is benefit from PCI or not.
- Here , this is a great meta-analysis show 6 out of 10 randomized trial exclude patient with HF , when CABG compared with PCI in Multiple vessel disease . You see 3% pt with these CABG had HF.
- These are not HF trial , when you look at the inclusion criteria.
- COURAGE which is a great and landmark trial but , they also excluded HF patient with LVEF < 30 %
- The SHOCK Trial – It is a great trial but it is a STEMI Trial. It is not HF trail
- Again, CUPRIT SHOCK Trial , people may think it is HF trial , actually it is heart attack with shock trial , patients in this trial had ventilated , resuscitate, high lactate level .
- What we have gained so far . We have some strong evidence on CS with AMI/ACS , but we still have to find out evidence for HHF without CS condition and CS not due to AMI/STEMI
- Again , here it is , there are great and landmark trials on CAD but not given answer for HF with CAD.
- Again, In Ischemia Trial , they exclude LVEF <35% , but included EF 35-45%,
- ISCHEMIA participants with stable ischemic heart disease and at least moderate ischemia with a history of HF or LVD were at increased risk for the primary outcome. In the small, high-risk subgroup with HF and LVEF 35% to 45%, an initial invasive approach was associated with better event-free survival.
- Of course , this is important data . The majority of patients hospitalized for new-onset HF did not receive testing for ischemic CAD either during hospitalization or within 90 days, which suggests significant underutilization of ischemic CAD assessment in new-onset HF patients.
- ESC 2021 HF Guideline
- This is a data , recently published in JACC, again, As we were saying , HFpEF is very big basket , we know it has varieties of phenotype . Among them , microvascular disease is a culprit of HFpEF, in that 51 % of HFpEF
- Since CAD is common in patients with HFpEF and is associated with increased mortality and greater deterioration in ventricular function. It is a positive study , that shows Revascularization may be associated with preservation of cardiac function and improved outcomes in patients with CAD. But this study did not assess the impact of revascularization on symptoms, because there was marked variability in follow-up duration and completeness of documentation of symptoms at subsequent visits. This study did not assess the impact of CAD or revascularization on recurrent HF hospitalizations. So, we will need prospective trials are urgently needed to determine the optimal evaluation and management of CAD in HFpEF.
- This nationwide study was recently published in EJHF . These data support the safety of CABG in HFpEF patients and suggest continuum of mortality risk for ischaemic HF when stratified by baseline ejection fraction before revascularization
- @HanCardiomd