Comparative Assessment of Revascularization Versus Drug Management in Coronary Artery Disease (CAD) Associated with Left Ventricular Dysfunction (EF <40%) – A 12 Month Study with FDG PET & SPECT MPI Analyses.
Left ventricular (LV) function and myocardial viability are among the most important determinants of prognosis in patients with coronary artery disease. Although survival of patients with heart failure is improved with drug therapy, it is important to learn about alternate therapy, revascularization and its effect on improving LV function.
The author V. Kumar and colleagues (2020) conducted a prospective study entitled, “Comparative Assessment of Revascularization Versus Drug Management in Coronary Artery Disease (CAD) Associated with Left Ventricular Dysfunction (EF <40%) – A 12 Month Study with FDG PET & SPECT MPI Analyses” published in the “Journal of the Association of Physicians of India”. The summary of the study is given below:
Objective:
To assess the prognosis after coronary revascularization (percutaneous coronary intervention/coronary artery bypass graft) or drug management in patients of coronary artery disease (CAD) with LV dysfunction (EF <40%) with viable myocardium, using fluorodeoxyglucose (FDG) positron emission tomography (PET) and single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI).
Method:
It is a single-centre, intervention study. 92 Patients with stable CAD and Left Ventricular Ejection Fraction (LVEF ≤40%) were enrolled. Patients enrollment was done after assessing the symptoms of the patients using classification New York Heart Association (NYHA) 5 functional class.
Inclusion Criteria: ≥18 years of age suffering stable coronary artery disease with LV dysfunctions (EF ≤ 40 %).
Exclusion Criteria: Lack of consent and patients with co-morbidities such as chronic kidney disease (CKD), carcinoma, chronic liver disease (CLD), cerebrovascular accident (CVA) that would possibly affect their survival during the study duration, history of MI ≤ 4 weeks, patients unsuitable for revascularization and or requiring emergency revascularization or severe valvular disease indicating surgery.
All the subjects underwent FDG-PET and SPECT-MPI for viability and reversible myocardial
ischemia. 20 patients with non-viable myocardium were thus excluded from the study. 72 met the inclusion criteria and were enrolled. 46 patients underwent revascularization and 26 patients refused revascularization and were put on medical therapy. Patients were classified into 2 groups: revascularization group and medical management group. Follow up of patients enrolled in the study was done at 3, 6 and 12 months.
The primary endpoint of the study was: change in ejection fraction, change in left ventricular end-systolic volume index (LVESVI), end-diastolic volume index (LVEDVI) and LV sphericity index (LVSI), change in NYHA functional class.
The secondary endpoint was any major adverse cardiac events (MACE)
Result:
At baseline, NYHA functional class of patients, the LVEF and cardiac volume (LVESVI, LVEDVI and LVSI) were similar and comparable in revascularization and medical management group.
In Revascularization group:
At 6 months’ follow up:
• LVEF improved from 24 ± 7 % at baseline to 27 ± 5 % (mean ± SD)
• LVEDVI decreased from 119 ± 23 (mean ± SD) at baseline to 109 ± 24 (P < 0.001)
• LVESVI decreased from 82 ± 19 (mean ± SD) at baseline to 75 ± 17 (P < 0.001)
• LVSI decreased from 0.69 ± 0.14 (mean ± SD) at baseline to 0.58 ± 0.11
• NYHA functional class improved from 2.9 ± 0.3 at baseline to 2.3 ± 0.5 (mean ± SD) (p < 0.01)
At 12 months’ follow up:
• LVEF improved from 24 ± 7 at baseline to 29 ± 8 (mean ± SD) (P < 0.001)
• LVEDVI decreased from 119 ± 23 (mean ± SD) at baseline to 101 ± 29 (P < 0.001)
• LVESVI decreased from 82 ± 19 (mean ± SD) at baseline to 69 ± 16 (P < 0.001)
• LVSI decreased from 0.69 ± 0.14 (mean ± SD) at baseline to 0.53 ± 0.12 (P < 0.001)
• NYHA functional class improved from 2.9 ± 0.3 at baseline to 2.0 ± 0.4 (mean ± SD)
In Medical Management group:
At 6 months’ follow up:
• no statistically significant change in mean LVEF, LVESVI, LVEDVI, LVSI and NYHA functional class.
At 12 months’ follow up:
• LVEF improved from 25 ± 6 (mean ± SD) at baseline to 23 ± 5 % (p < 0.01).
• LVEDVI increased from 113 ± 29 (mean ± SD) at baseline to 121 + 29 (p < 0.01)
• LVESVI increased from 79 ± 20 (mean ± SD) at baseline to 86 ± 17 (p < 0.01)
• LVSI changed from 0.65 + 0.12 (mean ± SD) at baseline to 0.65 ± 0.16 (p < 0.01)
• NYHA functional class changed from 2.7 ± 0.5 (mean ± SD) at baseline to 3.0 ± 0.3 (P =0.03)
In comparison to the medical management group, the revascularization group had statistically significant improvement in mean LVEF, LVEDVI, LVESVI, LVSI and NYAH functional class at 6 and 12 months of follow up.
Out of the total 15, 7 MACE and 8 MACE was witnessed in revascularization and medical management groups, respectively.
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