Prof. Peter Sleight,
This was a lively debate where both debaters often used data from the same trials – selected of course to suit their own arguments. O’Connor used data which showed that for some patients revascularisation by either PCI or CABG clearly could improve ventricular function. He also made the point that it was logical to improve blood flow to underperfused but viable muscle. He emphasised the favourable longterm results of the STICH study ((NEJM 2011). Cleland agreed with this, but pointed out several problems.
Perhaps a little dubiously he argued that the benefits seen for angina relief might be due to operative infarction of previously underperfused myocardium. He also pointed out that the STICH randomised trial (1212 participants) had shown an initial 4% excess mortality from revascularisation, which had taken 6 years to reverse to a 7% survival advantage. The problem with the arguments in this debate was the lack of adequate trial data. This is understandable since it is very difficult to recruit & carry out trials with adequate numbers in heart failure patients.
This debate continued the theme of the 1st debate. Camici began by emphasising the concept of the need to identify viable but malfunctioning myocardium. He cited the pooled analysis by Allman et al (JACC 2002) of the survival of over 3000 patients with prior LV dysfunction. The annual mortality rate after revascularisation when revascularisation was done where there was viable myocardium was 3.2 % versus 16% for medical treatment; for patients with non-viable myocardium revascularisation increased mortality from 6.2 to 7.7%. He also quoted the Velasquez & Bonow articles (NEJM 2011) which showed highly significant benefits only for patients with viable myocardium. But he also pointed out the limitations of this STICH data (see Cleland, above). He emphasised the need for better data – such as is planned for the current REMEDYS trial & registry (Revascularisation versus Medical Therapy for Iscaemic Ventricular Dysfunction. Meier responded by reviewing the concept of myocardial hibernation, as originally described by both Rahimtoola (Circulation 1985, & also Braunwald JACC 1986). He then highlighted the radiation risk involved in many of these studies. He showed data from revascularisation done solely on the basis of coronary arteriography – a necessary prelude for revascularisation in the majority of centres. He postulated that it was necessary to concentrate on a treatable stenosis in the artery supplying dysfunctional myocardium. He favoured PCI for single lesions & CABG for suitable multiple stenoses. He did not favour PCI where Q waves were present. He finished with the metanalysis by Pursani (Circ. Cardiovasc. Intervent. 2012) showing no differences in mortality between PCI & optimal medical treatment. In summary these 2 debates gave a very good overview of our current knowledge of this difficult area & demonstrated the need to pursue larger trials.
Controversial issues in chronic ischaemic heart failure
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