PCI not better than GDMT in severe ischaemic cardiomyopathy

Coronary revascularisation with multivessel percutaneous coronary intervention (PCI) failed to show additional survival benefit beyond guideline-directed medical therapy (GDMT) alone in patients with severely impaired left ventricular function and extensive coronary artery disease (CAD), according to results from the REVIVED-BCIS2 trial.

The secondary study of the REVIVED-BCIS2 trial (NCT01920048) set out to test 4 hypotheses, namely (1) that viability characterisation predicts event-free survival; (2) that this characterisation predicts left ventricular (LV) recovery; (3) that it can predict response to PCI or medical therapy; and (4) that LV recovery predicts event-free survival. Prof. Divaka Perera (King's College London, UK) explained that viability was assessed in 2 directions: as potential for recovery (n=610), and as presence of scar tissue (n=478) [1].

The 700 participants had a left ventricular ejection fraction (LVEF) of ≤35% and extensive coronary disease (British Cardiovascular Intervention Society Jeopardy Score ≥6) and viability in ≥4 dysfunctional myocardial segments. They were randomised to multivessel PCI (n=347) or GDMT (n=353). The mean age was 70 years, 13% were women, and 39% had diabetes. The duration of follow-up was 3.4 years.

Looking at all-viable myocardium, including all the normal segments, patients with a higher LVEF had a lower risk of all-cause mortality or heart failure hospitalisation (adjusted HR per 10% increase in viable myocardial volume: 0.93; 95% CI 0.87–1.00; P=0.048). In patients with a dysfunctional-yet-viable myocardium at baseline, this interaction was not present (adjusted HR per 10% increase in volume 0.98; 95% CI 0.93–1.04; P=0.56).

In patients with scar burden, the adjusted HR per 10% increase in scar volume was 1.18 (95% CI 1.04–1.33; P=0.009), a “highly significant” result. Furthermore, no impact was seen of viability assessment (i.e. abundance of dysfunctional-yet-viable segments or scar burden) on the effect of PCI versus GDMT (all P values were non-significant). Lastly, reverse LV remodelling (≥4.7%) lowered the incidence of all-cause death or heart failure hospitalisation versus no remodelling (HR 0.62; 95% CI 0.41–0.95; P=0.029).

Prof. Perera concluded that assessing viability characteristics at baseline does not allow for the selection of patients with ischaemic cardiomyopathy who will benefit more from PCI than from GDMT alone. “We also found that the abundance of dysfunctional-yet-viable segments was not associated with prognosis or likelihood of LV recovery. This result is perhaps surprising as it challenges the idea of hibernation.” However, characterising the myocardium in terms of scar burden is highly predictive of LV recovery, independent of baseline LVEF or the extent of CAD. “In fact, if you were to correct LVEF for scar burden, it is no longer associated with outcome or early recovery.” Finally, this trial confirmed that an improved LVEF improves prognosis.

1. Perera D, et al. Effect Of Myocardial Viability, Percutaneous Coronary Intervention And Functional Recovery On Clinical Outcomes In The REVIVED-BCIS2 Randomized Trial. Session 403-10, ACC Scientific Session 2023, 4–6 March, New Orleans, USA.

 

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Posted on 7 June 202323 April 2024