The Heart Failure Revascularisation Trial (HEART)

Abstract

AimsRevascularization is frequently advocated to improve ventricular function and prognosis for patients with heart failure due to coronary artery disease, especially when there is evidence of extensive myocardial viability. Methods and resultsPatients with heart failure, coronary artery disease, and a left ventricular (LV) ejection fraction ,35%, who had a substantial volume of viable myocardium with contractile dysfunction assessed by any standard imaging technique, were randomly assigned to a strategy of conservative management vs. angiography with the intent of percutaneous or surgical revascularization. Patients requiring revascularization for angina or too frail for surgery were excluded. Only 138 of the planned 800 patients were enrolled because of withdrawal of funding due to slow recruitment. Also, a larger trial (The Surgical Treatment for Ischemic Heart Failure Trial) addressing a similar question became available, which investigators were encouraged to join. Of 69 patients assigned to the invasive strategy, 6 refused angiography, 2 died as a result of the diagnostic procedure, 14 were considered unsuitable for revascularization, 2 refused surgery, and 45 had revascularization. After a median follow-up of 59 (inter-quartile range: 33 -63) months, there were 51 (37%) deaths; 25 (37%) in those assigned to the conservative strategy, and 26 (38%) in those assigned to the invasive strategy, 13 (29%) of whom had been revascularized. ConclusionA conservative management strategy may not be inferior to one of coronary arteriography with the intent to revascularize in patients with heart failure, LV systolic dysfunction, and extensive myocardial viability. However, this study was underpowered and, further, larger trials are required to settle this issue.

Coronary Artery Bypass Surgery in Patients with Left Ventricular Dysfunction

“…[10][11][12][13] More recently, observational analyses supporting a benefit of CABG 14 and the proliferation of contemporary evidence-based medical and device-associated therapies have led to substantial clinical uncertainty regarding the incremental benefits of CABG relative to its risks in patients with ischemic cardiomyopathy. 15,16 We designed the Surgical Treatment for Ischemic Heart Failure (STICH) trial to evaluate the role of cardiac surgery in the treatment of patients with coronary artery disease and left ventricular systolic dysfunction. A major hypothesis of the trial was that CABG plus intensive medical therapy based on current guidelines, as compared with medical therapy alone, would reduce mortality.…”

Review: Do We Still Need a Viability Study before Considering Revascularization in Patient with Stable Coronary Artery Disease and Significant Left Ventricular Systolic Dysfunction?

“…The lack of randomized controlled trials (RCT) of viability testing was addressed partly by the PARR-2 trial, the largest to date, RCT of PET viability testing [22]. PARR-2 stratified patients with severe LV systolic dysfunction (presumed ischemic) to recent angiography or not, then randomized to PET-guided management (n = 218) versus standard care without PET (where an alternative test could be considered [n = 212]).…”

Noninvasive assessment myocardial viability: Current status and future directions

“…The UK HEART trial 137,138 illustrates the problem of lower than anticipated patient enrollment. This investigator-initiated study was funded by the Medical Research Council of the United Kingdom.…”