Late-Breaking Science: Initial invasive or conservative treatment for patients with stable ischaemic heart disease and a history of heart failure?

In a Late-Breaking Science presentation today, Professor Renato Lopes (Duke Clinical Research Institute, Durham, NC, USA) described a comparison of CV outcomes in ISCHEMIA participants with a history of heart failure (HF) or left ventricular dysfunction (LVD) (defined as prior HF or LVEF <45% at randomisation) vs. those without a history of HF/LVD over the median 3.2-year follow-up period.

Of the total 5,179 patients studied in ISCHEMIA, 398 patients (7.7%) had prior HF/LVD and these patients had more comorbidities, particularly prior myocardial infarction (MI), stroke and hypertension than patients with no prior HF/LVD. Furthermore, the primary endpoint of ISCHEMIA (CV death, nonfatal MI, or hospitalisation for unstable angina, HF or resuscitated cardiac arrest) occurred more frequently in patients with a history of HF/LVD (4­-year cumulative incidence rate: 22.7% vs. 13.8%).

The key result of Prof. Lopes’ presentation was that patients with a history of HF/LVD had lower risk of the primary endpoint with an invasive strategy (17.2%) compared with an initial conservative strategy (29.3%). Consistent with the overall trial conclusion, there was no difference between groups for the primary endpoint in patients without a history of HF/LVD (p-interaction=0.055). Similar results were seen for the primary outcome with HF/LVD groups and non-HF/LVD groups when LVEF was analysed as a continuous variable.

These note-worthy findings suggest patients with stable ischaemic heart disease and a history of HF/LVD may derive benefit from an initial invasive strategy – this information might help physicians in the decision-making process when treating these high-risk patients.