Importance of Angina in Patients With Coronary Disease, Heart Failure, and Left Ventricular Systolic Dysfunction

Abstract

Background Patients with left ventricular (LV) systolic dysfunction, coronary artery disease (CAD), and angina are often thought to have a worse prognosis and a greater prognostic benefit from coronary artery bypass graft (CABG) surgery than those without angina. Objectives We investigated whether: 1) angina is associated with a worse prognosis; 2) angina identified patients who had a greater survival benefit from CABG; and 3) whether CABG improved angina in patients with LV systolic dysfunction and CAD. Methods We performed an analysis of the Surgical Treatment for Ischemic Heart Failure trial, in which 1,212 patients with an ejection fraction ≤35% and CAD were randomized to CABG or medical therapy. Multivariable Cox and logistic models were used to assess long-term clinical outcomes. Results At baseline, 770 patients (64%) reported angina. Amongst patients assigned to MED, all-cause mortality was similar in patients with and without angina (HR: 1.05; 95% CI: 0.79 to 1.38). The effect of CABG was similar whether the patient had angina (HR: 0.89; 95% CI: 0.71 to 1.13) or not (HR: 0.68; 95% CI: 0.50 to 0.94) (p interaction = 0.14). Patients assigned to CABG were more likely to report improvement in angina than those assigned to medical therapy alone (OR: 0.70; 95% CI: 0.55 to 0.90; p < 0.01). Conclusions Angina does not predict all-cause mortality in medically treated patients with LV systolic dysfunction and CAD, nor does it identify patients who have a greater survival benefit from CABG. However, CABG does improve angina to a greater extent than medical therapy alone. (Comparison of Surgical and Medical Treatment for Congestive Heart Failure and Coronary Artery Disease [STICH]: NCT00023595)

ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012

“…174,177,383,384 The clinical relevance of myocardial ischaemia for the provocation of ventricular arrhythmias is uncertain, although anecdotal cases of ischaemia-induced arrhythmias exist. Randomized trials of revascularization for patients with HFrEF have not reduced overall mortality, 107,385 even in subgroups of patients with angina or myocardial ischaemia, 115,386 but further analysis did suggest a reduction in sudden deaths. 387 Amiodarone (often in combination with a beta-blocker) may be used to suppress symptomatic ventricular arrhythmias, but it may adversely affect prognosis, especially in patients with more severe HF.…”

2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure

“…Koronarografia jest wskazana u pacjentów z HF oraz nawracającymi, opornymi na leczenie bólami w klatce piersiowej [115], zakładając że pacjent jest kandydatem do rewaskularyzacji. Koronarografia jest również wskazana u pacjentów z wywiadem objawowych komorowych zaburzeń rytmu oraz po przebytym zatrzymaniu krążenia.…”

“…Wyniki badań randomizowanych wykazały, że rewaskularyzacja u pacjentów z HF nie zmniejsza śmiertelności całkowitej [107,385], nawet w podgrupie osób z obecnymi dławicowymi lub potwierdzonym niedokrwieniem mięśnia sercowego [115,386]. Dalsze analizy sugerowały jednak redukcję częstości nagłych zgonów [387].…”

“…W analizach post hoc badania STICH wykazano, że ani obecność indukowanego niedokrwienia mięśnia sercowego (w badaniu SPECT lub w próbie dobutaminowej), ani obecność objawowej dławicy nie wskazywały na gorsze rokowanie lub większą korzyść z CABG w porównaniu z OMT [115,386], przy czym CABG zmniejsza nasilenie objawów w większym stopniu niż sama OMT. Decyzja dotycząca wyboru metody rewaskularyzacji (CABG vs. PCI) powinna zapadać w ramach konsultacji kardiogrupy (Heart Team), po dokładnym przeanalizowaniu stanu klinicznego pacjenta, anatomii tętnic wieńcowych, prze- [414][415][416].…”

Invasive Treatment in Advanced (Stage-D) Heart Failure

“…Transmural distribution of the postinfarction scar, which spreads from the subendocardium to the subepicardium without intermittent viability, does not provide any benefit by angioplasty. Although surgical coronary revascularization is superior to medical therapy in patients with HF [20], there is no real superiority of surgery over angioplasty [21]. Contrarily, the positive benefit of percutaneous revascularization of the viable region is a significant improvement in the LVEF and LVESV in the LHF patients.…”