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Ischemia change in stable coronary artery disease is an independent predictor of death and myocardial infarction.
MedLine Citation:
PMID:  22789940     Owner:  NLM     Status:  In-Data-Review    
OBJECTIVES: The aim of this study was to evaluate the independent prognostic significance of ischemia change in stable coronary artery disease (CAD).
BACKGROUND: Recent randomized trials in stable CAD have suggested that revascularization does not improve outcomes compared with optimal medical therapy (MT). In contrast, the nuclear substudy of the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial found that revascularization led to greater ischemia reduction and suggested that this may be associated with improved unadjusted outcomes. Thus, the effects of MT versus revascularization on ischemia change and its independent prognostic significance requires further investigation.
METHODS: From the Duke Cardiovascular Disease and Nuclear Cardiology Databanks, 1,425 consecutive patients with angiographically documented CAD who underwent 2 serial myocardial perfusion single-photon emission computed tomography scans were identified. Ischemia change was calculated for patients undergoing MT alone, percutaneous coronary intervention, or coronary artery bypass grafting. Patients were followed for a median of 5.8 years after the second myocardial perfusion scan. Cox proportional hazards regression modeling was used to identify factors independently associated with the primary outcome of death or myocardial infarction (MI). Formal risk reclassification analyses were conducted to assess whether the addition of ischemia change to traditional predictors resulted in improved risk classification for death or MI.
RESULTS: More MT patients (15.6%) developed ≥5% ischemia worsening compared with those undergoing percutaneous coronary intervention (6.2%) or coronary artery bypass grafting (6.7%) (p < 0.001). After adjustment for established predictors, ≥5% ischemia worsening remained a significant independent predictor of death or MI (hazard ratio: 1.634; p = 0.0019) irrespective of treatment arm. Inclusion of ≥5% ischemia worsening in this model resulted in significant improvement in risk classification (net reclassification improvement: 4.6%, p = 0.0056) and model discrimination (integrated discrimination improvement: 0.0062, p = 0.0057).
CONCLUSIONS: In stable CAD, ischemia worsening is an independent predictor of death or MI, resulting in significantly improved risk reclassification when added to previously known predictors.
Afshin Farzaneh-Far; Harry R Phillips; Linda K Shaw; Aijing Z Starr; Mona Fiuzat; Christopher M O'Connor; Ashwani Sastry; Leslee J Shaw; Salvador Borges-Neto
Publication Detail:
Type:  Journal Article    
Journal Detail:
Title:  JACC. Cardiovascular imaging     Volume:  5     ISSN:  1876-7591     ISO Abbreviation:  JACC Cardiovasc Imaging     Publication Date:  2012 Jul 
Date Detail:
Created Date:  2012-07-13     Completed Date:  -     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  101467978     Medline TA:  JACC Cardiovasc Imaging     Country:  United States    
Other Details:
Languages:  eng     Pagination:  715-24     Citation Subset:  IM    
Copyright Information:
Copyright © 2012 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
Section of Cardiology, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois; Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina.
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