CLINICAL STUDY: CORONARY REVASCULARIZATION
Myocardial viability testing and impact of revascularization on prognosis in patients with coronary artery disease and left ventricular dysfunction: a meta-analysis
Kevin C. Allman, MB, BS, FRACP, FACC*,*,
Leslee J. Shaw, PhD ,
Rory Hachamovitch, MD, FACC and
James E. Udelson, MD, FACC
* Concord Hospital, Concord NSW, Australia
Atlanta Cardiovascular Research Institute, Atlanta, Georgia, USA
Tufts University School of Medicine/New England Medical Center Hospitals, Boston, Massachusetts, USA
Manuscript received May 22, 2001;
revised manuscript received October 10, 2001,
accepted January 10, 2002.
* Reprint requests and correspondence: Kevin C. Allman, Nuclear Cardiology Laboratory, Concord Hospital, Concord 2139, Australia
kevina{at}nucmed.crg.cs.nsw.gov.au
OBJECTIVES: This study pools data from published series examining late survival with revascularization versus medical therapy after myocardial viability testing in patients with severe coronary artery disease (CAD) and left ventricular (LV) dysfunction.
BACKGROUND: Previous observational studies have suggested survival benefit in such patients if they are revascularized when myocardial viability is detected on imaging tests.
METHODS: A MEDLINE database search returned 24 viability studies reporting patient survival using thallium perfusion imaging, F-18 fluorodeoxyglucose metabolic imaging or dobutamine echocardiography. Annual death rates were extracted, pooled and analyzed with a random effects model. The risk-adjusted relationship between severity of LV dysfunction, presence of viability and survival benefit associated with revascularization was assessed by meta-regression.
RESULTS: There were 3,088 patients (2,228 men), ejection fraction 32 ± 8%, followed for 25 ± 10 months. In patients with viability, revascularization was associated with 79.6% reduction in annual mortality (16% vs. 3.2%, chi-square = 147, p < 0.0001) compared with medical treatment. Patients without viability had intermediate mortality, trending to higher rates with revascularization versus medical therapy (7.7% vs. 6.2%, p = NS). Patients with viability showed a direct relationship between severity of LV dysfunction and magnitude of benefit with revascularization (p < 0.001). There was no measurable performance difference for predicting revascularization benefit between the three testing techniques.
CONCLUSIONS: This meta-analysis demonstrates a strong association between myocardial viability on noninvasive testing and improved survival after revascularization in patients with chronic CAD and LV dysfunction. Absence of viability was associated with no significant difference in outcomes, irrespective of treatment strategy.
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Abbreviations and Acronyms
| | CAD | | coronary artery disease | | DASE | | dobutamine/atropine stress echocardiography | | EF | | ejection fraction | | FDG | | F-18 fluorodeoxyglucose | | LDDE | | low-dose dobutamine echocardiography | | LV | | left ventricular | | LVEF | | left ventricular ejection fraction | | NYHA | | New York Heart Association | | PET | | positron emission tomography | | RALES | | Randomized Spironolactone Evaluation study | | SPECT | | single photon emission computed tomography |
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