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Review
. 2023 Dec 4;2(6Part B):101197.
doi: 10.1016/j.jscai.2023.101197. eCollection 2023 Nov-Dec.

Current Landscape and Future Directions of Coronary Revascularization in Ischemic Systolic Heart Failure: A Review

Katherine Lee Chuy  1 , Eric J Velazquez  2 , Alexandra J Lansky  2 , Yasser Jamil  2 , Yousif Ahmad  2
Affiliations
Review

Current Landscape and Future Directions of Coronary Revascularization in Ischemic Systolic Heart Failure: A Review

Katherine Lee Chuy et al. J Soc Cardiovasc Angiogr Interv. .

Abstract

Ischemic heart disease is the largest cause of death worldwide and the most common cause of heart failure (HF). The incidence and prevalence of HF are increasing owing to an aging population and improvements in the acute cardiac care of previously fatal conditions such as myocardial infarction. Strategies to improve outcomes in patients with ischemic systolic HF are urgently needed. There is systematic underutilization of testing for coronary artery disease in patients with HF, and revascularization is performed in an even smaller minority despite evidence for reduced mortality with coronary artery bypass grafting (CABG) over medical therapy in the Surgical Treatment for Ischemic Heart Failure Extension Study. Percutaneous coronary intervention (PCI) is a less-invasive approach to coronary revascularization; however, the recent Revascularization for Ischemic Ventricular Dysfunction (REVIVED)-British Cardiovascular Intervention Society (BCIS2) trial failed to demonstrate a benefit of PCI compared with that of medical therapy in patients with ischemic systolic HF. The comparative effectiveness of PCI and CABG for patients with ischemic systolic HF remains unknown, particularly in the era of contemporary medical therapy. In this review, we discuss the benefit of CABG in ischemic systolic HF, its underutilization, and the unmet clinical need. We also review the recent REVIVED-BCIS2 trial comparing PCI to medical therapy, as well as upcoming randomized controlled trials of PCI for ischemic systolic HF and persistent evidence gaps that will exist despite anticipated data from ongoing trials. There remains a need for an adequately powered randomized controlled trials to establish the comparative clinical effectiveness of PCI vs CABG in ischemic systolic HF in the era of contemporary revascularization approaches and medical therapy, as well as trials of coronary revascularization in patients with HF with preserved ejection fraction or less severe forms of left ventricular systolic dysfunction.

Keywords: heart failure; percutaneous coronary intervention; revascularization.

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Figures

None
Graphical abstract
Figure 1
Figure 1
Mortality trends for major causes of death from 2005 to 2015 in various countries, demonstrating ischemic heart disease as the leading cause of death. Age-standardized mortality rates per 100,000 people from ischemic heart disease (red line), stroke (light blue line), cirrhosis and other liver diseases (green line), chronic lower respiratory tract diseases (yellow line), lung cancer (blue line), transport accidents (orange line), and infectious diseases (purple line). Reproduced with permission from Nowbar et al.
Figure 2
Figure 2
(Top panel) Significant variability demonstrated in cumulative distribution curves of cardiologists ordering CAD testing. (Bottom panel) CAD testing rates shown with the publication dates of the STICH and STICHES publications denoted, with no significant increase in rates of CAD testing after these publications. Reproduced with permission from Zheng et al. CAD, coronary artery disease.
Figure 3
Figure 3
Kaplan-Meier analysis of patients assigned to coronary artery bypass graft (CABG; blue lines) or medical therapy alone (MED; red lines) either adhering (per-protocol) or not adhering (crossover) to their randomly assigned treatment. This analysis demonstrated that CABG reduced mortality in the intention-to-treat, per-protocol, and crossover populations. Reproduced with permission from Doenst et al.
Figure 4
Figure 4
Hazard ratio (solid line) and 95% CI (gray area) for the effect of coronary artery bypass grafting vs medical therapy across the range of ages. The effect of CABG on reducing clinical events was greater in the younger (<54 years) compared with older patients (>67 years). Reproduced with permission from Petrie et al.
Figure 5
Figure 5
Kaplan-Meier estimates of the cumulative incidence of all-cause mortality or hospitalization for heart failure in the REVIVED-BCIS2 trial. Reproduced with permission from Perera et al.
Figure 6
Figure 6
Association between randomized treatment and outcomes for patients with and without heart failure (HF) or left ventricular dysfunction (LVD) at baseline. A total of 398 patients had a history of HF or LVD (214 in the invasive arm and 184 in the conservative arm). Outcomes in the invasive arm seem to be better in patients with HF or LVD, particularly for the primary end point and for the end point of cardiovascular death or myocardial infarction. Reproduced with permission from Lopes et al.
Central Illustration
Central Illustration
IHD is the most common cause of HF, with rising prevalence worldwide. Coronary evaluation in HF remains widely underutilized, and revascularization remains low despite demonstrated mortality benefit of CABG. While each strategy offers unique advantages, there are currently no direct comparisons on clinical effectiveness between percutaneous versus surgical revascularization. Despite ongoing trials on percutaneous revascularization in ischemic systolic HF, persistent evidence gaps exist. CABG, coronary artery bypass grafting; CAD, coronary artery disease; DAPT, dual antiplatelet therapy; HF, heart failure; IHD, ischemic heart disease; QoL, quality of life; PCI, percutaneous coronary intervention; RCT, randomized controlled trial.
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