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JACC State-of-the-Art Review: Impact of Percutaneous Coronary Intervention on Outcomes in Patients with Heart Failure

October 20, 2021.
Puja Parikh, MD, MPH, FACC, Stony Brook, NY
Roxana Mehran, MD, FACC, New York, NY

Educational Objectives


After completing the activity, the clinician will be better able to review data about the use of percutaneous coronary intervention in heart failure patients with coronary artery disease.

Summary


JACC State-of-the-Art Review: Impact of Percutaneous Coronary Intervention on Outcomes in Patients with Heart Failure

Correspondent: Maya Ignaszewski, MD, Chicago, IL

Take-home Messages:

  • Coronary artery disease (CAD) remains the most common cause of heart failure in the United States, accounting for nearly two-thirds of cases. Coronary artery bypass grafting (CABG) has long been the mainstay of treatment for patients with multivessel CAD and reduced ejection fraction (EF). But in this contemporary era of percutaneous coronary intervention (PCI), newer PCI optimization strategies are available — newer-generation drug-eluting stents, antiplatelet therapy, percutaneous mechanical circulatory support devices, and the use of intravascular imaging studies.
  • The underutilization of coronary angiography in patients hospitalized with acute heart failure correlates with low rates of revascularization with PCI in these patients. Coronary angiography is performed in only 10% to 15% of patients during the index hospitalization, and <20% of patients undergo coronary angiography within 90 days of their hospitalization. Rates of revascularization with PCI are even lower (<5% within the index hospitalization).
  • Patients hospitalized with acute heart failure should undergo coronary angiography after diuresis. In patients with evidence of triple-vessel disease, the optimal management strategy (eg, performing viability studies or fractional flow reserve assessments to determine the need for revascularization or medical therapy alone) is unclear as more randomized trial data are needed.
  • Observational studies have demonstrated that PCI is certainly feasible in patients with moderately to severely reduced EF.
  • Randomized controlled trials (eg, BARI 2D, FREEDOM) that compared PCI with CABG or with medical therapy in patients with stable CAD typically have excluded patients with severely reduced EF (or included only small number of heart failure patients).
  • Observational studies and propensity score analyses that compare PCI with CABG in patients with heart failure with reduced ejection fraction (HFrEF) yield conflicting results, with a majority of studies suggesting greater long-term benefit with CABG than with PCI.
  • There is also a lack of randomized data comparing PCI with medical therapy in patients with HFrEF. Observational studies have demonstrated that >50% patients with severely reduced EF experience varying degrees of improvement in EF after PCI, with greater improvements being correlated with treatment of a greater number of vessels.
  • The REVIVED-BCIS2 trial, which aims to provide randomized data about the efficacy and safety of PCI in HFrEF patients, is currently underway. Investigators will compare a PCI strategy with optimal medical therapy vs medical therapy alone in ≈700 patients with EF ≤35%.
  • Studies looking at the use of mechanical support devices in PCI patients with shock found no mortality benefit (mainly because of the heterogeneity in, eg, the definition of shock, systems of care for shock, and the timing of mechanical support implementation). Outside the setting of shock, mechanical support devices were found to have no effect on infarct size or mortality in patients with acute coronary syndrome undergoing PCI.
  • Upcoming randomized controlled trials (eg, STEMI-DTU) will compare outcomes (eg, infarct size, mortality) in patients with ST-segment-elevation myocardial infarction undergoing PCI with Impella mechanical support.

Reference

1. Parikh PB, Bhatt DL, Bhasin V, et al. Impact of percutaneous coronary intervention on outcomes in patients with heart failure: JACC State-of-the-Art Review. J Am Coll Cardiol. 2021;77(19):2432-2447. doi:10.1016/j.jacc.2021.03.310

Readings


Disclosures


Puja Parikh: Consultant Fees/Honoraria: Medtronic.

Roxana Mehran: Consultant Fees/Honoraria: Boston Scientific, Cine-Med Research Institute, Janssen Pharmaceuticals, Inc.; Other: Elixir Medical, WebMD; Ownership Interest/Partnership/Principal: Applied Therapeutics, ControlRad, STEL; Research/Research Grants: Abbott Laboratories, Abiomed, AstraZeneca, Bayer, Beth Israel Deaconess Medical Center, Bristol Myers Squibb, CERC, Chiesi, Concept Medical, CSL Behring, DSI, Medtronic, Novartis, OrbusNeich.

Acknowledgements


CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

AC531011

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

More Details - Certification & Accreditation