Revascularization in ischaemic heart failure with preserved ejection fraction: a nationwide cohort study

Abstract

Aims Despite the common occurrence of coronary artery disease (CAD) and heart failure (HF) with preserved ejection fraction (HFpEF), there is limited evidence to guide revascularization. Methods and Results We investigated the long‐term outcomes of coronary artery bypass grafting (CABG) in patients with HF and significant CAD across the spectrum of ejection fraction, using a large national cohort of patients from the Veteran Affairs (VA) Medical Centers in the US. Patients with HF were stratified into groups, HFpEF, HF with mid‐range ejection fraction (HFmrEF), and HF with reduced ejection fraction (HFrEF) and compared to patients with no preoperative HF. We analysed 10 396 patients. Despite an increased hazard in the first year following revascularization, the long‐term survival (median follow‐up 6.6 years; interquartile range 3.7–10.1) of HFpEF post‐CABG was similar to controls (hazard ratio 0.85, 95% confidence interval 0.68‐1.06), but survival progressively declined with HFmrEF and HFrEF. Similar trends were seen with recurrent HF hospitalization with lower risk with baseline HFpEF (43.9 ± 6.9/100 patient‐years) compared to HFmrEF (65.9 ± 3.8/100 patient‐years) and HFrEF (93.4 ± 4.8/100 patient‐years). Although HFpEF patients had lower mortality and HF hospitalization post‐CABG compared to patients with a lower ejection fraction, they experienced the highest rates of future myocardial infarction. Conclusion Although HFpEF patients with CAD have greater short‐term risk post‐CABG, their long‐term survival is comparable to controls. However, they are at increased risk for HF hospitalizations and myocardial infarction. These data support the safety of CABG in HFpEF patients and suggest continuum of mortality risk for ischaemic HF when stratified by baseline ejection fraction before revascularization.

August 2022 at a glance: focus on heart failure with preserved ejection fraction and cardiac amyloidosis

“…Mortality and HF hospitalizations progressively increased as the ejection fraction decreased. Patients with HFpEF had a long‐term survival after CABG similar to patients without preoperative HF, though they had the highest rate of recurrent myocardial infarction 22 …”

“…Patients with HFpEF had a long-term survival after CABG similar to patients without preoperative HF, though they had the highest rate of recurrent myocardial infarction. 22…”

Validating the SMART2 Score in a Racially Diverse High‐Risk Nationwide Cohort of Patients Receiving Coronary Artery Bypass Grafting

“…We obtained vital status data (current until December 31, 2021, at the time of analysis) from the National Death Index, supplemented by information from the Social Security Index, Beneficiary Identification Records Locator Subsystem, and the Center for Medicare and Medicaid Services. 15 , 16 We further obtained the cause of death from the VA Mortality Data Repository 17 and identified those patients who experienced cardiovascular mortality using the ICD‐9 and ICD‐10 codes listed as the primary cause of death. We identified the first date after surgery that patients were admitted for a primary diagnosis of myocardial infarction or ischemic stroke.…”

Patient phenotype profiling in heart failure with preserved ejection fraction to guide therapeutic decision making. A scientific statement of the Heart Failure Association, the European Heart Rhythm Association of the European Society of Cardiology, and the European Society of Hypertension

“…They are related to more severe haemodynamic impairment and worse prognosis. They are therefore potential therapeutic targets for patients with HFpEF as supported by results from observational studies 131,132 . However, long‐term randomized studies are required to definitively determine the safety and efficacy of revascularization in this population, and in whom exactly to apply such therapy (e.g.…”