P6474Contemporary management of coronary artery disease in heart failure with reduced ejection fraction. Guidelines meet clinical practice

Abstract

Background: Heart failure (HF) is the major cause of death in cardiovascular disease. In a post-STICH era, coronary artery bypass grafting (CABG) remains the only randomized trial verified form of coronary artery disease (CAD) treatment. However, in everyday clinical practice the role of percutaneous revascularization (PCI) in growing, while a significant population of patients remain treated medically (OMT). Data on real-life treatment of coronary artery disease in HF patients remains extremely scarce. Purpose: Having at our disposal a large cohort of systolic ischemic HF patients we have decided to analyze the treatment modalities and outcomes in this population. Methods: We have analyzed a large single-center registry (n=2730) of systolic HF patients treated for the first time in a large-volume cardiovascular center (2009-2015). Acute coronary syndromes on admission were excluded. An analysis of demographic and clinical data, treatment modalities and outcomes has been performed in a subgroup of patients with ischemic etiology (n=1703). Results: The analysis of demographic and clinical data of the ischemic revealed a group of patients with large burden of comorbidities (mean age 64,8±10,4 y.o.; NYHA class III and IV 51,8%; hypertension 60,8%; diabetes mellitus 46,0%; atrial fibrillation 24,8%; obstructive pulmonary disease 11,1%; anemia 40,1%; chronic kidney disease stage III-V 34,0%; history of stroke 7,8%; history of myocardial infarction 67,7%; history of CABG 22,1%; history of PCI 65,9%). Mean left ventricular ejection fraction was 26,3±5,9% and mean end-diastolic volume 196±81 ml. Cardiac resynchronization therapy defibrillators or implantable cardioverter defibrillators were implanted in 65,9% of subjects. In this population 69,7% of patients were qualified for coronary angiography. Significant lesions were observed in 76,8% of cases. Only 11,5% of patients were subsequently qualified for CABG, while 28,3% were treated medically. PCI was the dominant form of treatment (60,2%), with 33,1% of multivessel-PCI procedures. 4,5% of patients were qualified of heart transplantation. Overall 12-month all-cause mortality in this population was 12,7%. In the PCI and CABG group mortality was equal (10,4%) and significantly lower than in the OMT group (18,9%; p<0,01). The results of Cox regression analysis are presented in figure 1, showing that aside typical HF interventions (ICD, beta-blockers, ACE-inhibitors), achievement of complete revascularization was related to improved outcomes (HR 0,49, 95% CI 0,3-0,8, p=0,004). Conclusions: The analysis shows that in every-day clinical practice PCI is the dominant form of coronary artery disease treatment in patients with HF and is related to satisfactory results in this difficult patient population.