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Hot topics in myocardial revascularisation and ICDs tackled at Heart Failure 2017

Unresolved issues surrounding myocardial revascularisation and implantable cardioverter defibrillators (ICD) take centre stage at the second of the Grand Debates being held at Heart Failure 2017. The double-stranded discussion will deliberate on the benefits of using an ICD in patients with non-ischaemic heart failure and review the value of Surgical Treatment for IsChaemic Heart failure (STICH).

Heart Failure

Supporting the role of ICDs is Professor Lars Kober (Rigshospitalet, University of Copenhagen, Denmark). Arguing against the proposal is Professor John Cleland (Royal Brompton/Imperial College London, London, UK).

The 2016–2018 Heart Failure Association President Professor Frank Ruschitzka, who will provide the introduction to the debate, said ICDs were “life-saving therapies for many but not all patients with heart failure”. He added that as “a doctor, you want to identify the patient who is going to benefit from such a device and, importantly, who is not”. Furthermore, Prof. Ruschitzka commented, there has been a long-standing debate about whether or not patients with non-ischaemic heart failure benefitted from an ICD. The DANISH study, which last year showed that only non-ischaemic heart failure patients under the age of 68 years benefitted from ICDs (compared with older patients with non-ischaemic heart failure), has added to the debate.

“The expense and uncertainty of 
ICD therapy requires a more individualised, patient-centred approach. If you identify a patient who is unlikely to benefit from the ICD implantation, then you have spared a potentially unnecessary and costly procedure.” Prof. Ruschitzka states.

The second strand of the debate pits Dr. Eric J Velazquez (Duke University Hospital, Durham, USA) against Dr. Divaka Perera (Guy’s and St Thomas’ Hospital/King’s College, London, UK). Dr. Velazquez—who has been the principal investigator for the STICH trial programme for the past 15 years—will be arguing in favour of the motion “Surgical revascularisation beats optimal medical therapy in ischaemic heart failure” while Dr. Perera, chief investigator of REVIVED (Revascularisation of ischaemic ventricles study) will be arguing against this motion.

Dr. Velazquez believes that the European guidelines on revascularisation in heart failure are lagging behind the evidence base and do not reflect the recent results of the extended STICH trial (STICHES). “The long-term results for STICH, published in April 2016, showed at 10 years very statistically significant differences in favour of coronary artery bypass grafting (CABG). That information is what is behind my confidence in promoting the pro argument at this debate,” he said.

Dr. Perera agrees that the guidelines do not include the most recent data from STICHES and predicts that the guidelines will be heavily discussed at the debate. However, he told Heart Failure 2017 Congress News: “CABG was a class I recommendation when the guidelines were published for a subgroup of patients with significant left main stenosis and proximal coronary artery disease. The interesting thing is that the STICH trial excluded this cohort of patients. The European guidelines are quite transparent in saying that ‘we think it should be done but there is not very good evidence for these types of patients’.”

Dr. Velazquez will argue that all patients should be considered for surgical revascularisation, although he accepts it will not necessarily be suitable for everyone. He said: “The decision really has to be individualised. Surgery has a 3% mortality risk within the first 30 days. But now with the STICHES results we can have informed decisions.” “My emerging belief about how STICH provides a long-term benefit is that the mechanism might be related to an avoidance of a fatal event because of the enhanced blood flow. We don’t know for sure—but that’s how I am starting to make sense mechanistically of our findings in patients,” he added.

On the other hand, Dr. Perera said that because STICH did not distinguish whether or not patients had viable myocardium, there was not enough evidence to show that it was better than medical therapy alone. “Let me summarise my interpretation of STICH,” he said. “There is a high likelihood that you will come to harm from surgery if you have such a poor ventricle to start with. But if you do survive the surgery, then having more blood to the heart muscle seems to be a good thing in the long term. We do have to tell our patients that there is a risk they could be worse off.”

He added: “This is why percutaneous coronary intervention (PCI) is a really important consideration; it may be that with PCI, we can give them the benefit of more blood to the heart muscle without the hit early on. That is going to be my position. It is going to be a really interesting debate; it is a very hot topic.”

Dr. Velazquez echoed his comments: “I think it will be a great debate. What we want is for the audience to leave with an understanding of how important coronary disease is in patients with heart failure and that we are starting to learn the impact of interventions. We have evidence in favour of surgery from STICH, and I think my opponent is also to be commended because he is starting to build an evidence base to understand if PCI would be an alternative.”

The Grand Debate II: ICD – Myocardial revascularisation

Implantable Cardioverter Defibrillator (ICD) - view the programme

STICH (Surgical Treatment for Ischemic Heart Failure) - view the programme