Journal of Nuclear Cardiology

, Volume 19, Issue 4, pp 658–669 | Cite as

Impact of left ventricular function and the extent of ischemia and scar by stress myocardial perfusion imaging on prognosis and therapeutic risk reduction in diabetic patients with coronary artery disease: Results from the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial

  • Leslee J. Shaw
  • Manuel D. Cerqueira
  • Maria M. Brooks
  • Andrew D. Althouse
  • Veronica V. Sansing
  • George A. Beller
  • Rodica Pop-Busui
  • Raymond Taillefer
  • Bernard R. Chaitman
  • Raymond J. Gibbons
  • Jaekyeong Heo
  • Ami E. Iskandrian
Original Article
First Online:
Received:
Accepted:

Abstract

Background

The Bypass Angioplasty Revascularization Investigation 2 Diabetes trial demonstrated similar long-term clinical effectiveness of revascularization (REV) and intensive medical (MED) therapy. Comparisons of post-intervention ischemic burden have not been explored but are relevant to treatment decisions. This study examined differences in 1-year stress myocardial perfusion SPECT (MPS) abnormalities by randomized treatment.

Methods

MPS was performed in 1,505 patients at 1-year following randomization. MPS images were analyzed (masked to treatment) by a Nuclear Core Laboratory using a quantitative percent (%) of total, ischemic, and scarred myocardium. Cox proportional hazards models were used to estimate the relationship between MPS variables and trial endpoints.

Results

At 1-year, nearly all REV patients underwent the assigned procedure; while 16% of those randomized to MED received coronary REV. Patients randomized to REV exhibited fewer stress perfusion abnormalities than MED patients (P < .001). CABG patients had more frequent ischemic and scarred myocardium encumbering ≥5% of the myocardium when compared to those receiving PCI. Patients randomized to MED had more extensive ischemia and the median % of the myocardium with perfusion abnormalities was lower following REV (3% vs 9%, P = .01). A total of 59% of REV patients had no inducible ischemia at 1-year compared to 49% of MED patients (P < .001). Within the CABG stratum, those randomized to MED had the greatest rate of ischemic (P = .032) and scarred (P = .017) perfusion abnormalities. At 1-year, more extensive and severe stress myocardial perfusion abnormalities were associated with higher 5-year rates of death and a combined endpoint of cardiac death or myocardial infarction (MI) rates (11.3%, 8.1%, 6.8%, for ≥10%, 5%-9.9%, and 1-4.9% abnormal myocardium at stress, respectively, P < .001). In adjusted models, selected MPS variables were significantly associated with an increased hazard of cardiac death or MI (hazard ratio = 1.11 per 5% increase in abnormal myocardium at stress, P = .004).

Conclusions

Patient management strategies that focus on ischemia resolution can be useful to guide the efficacy of near-term therapeutic approaches. A 1-year post-therapeutic intervention myocardial perfusion scan provides important information regarding prognosis in stable CAD patients with diabetes.

Keywords

Diabetes clinical trials myocardial perfusion imaging ischemia 
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Copyright information

© American Society of Nuclear Cardiology 2012

Authors and Affiliations

  • Leslee J. Shaw
    • 1
  • Manuel D. Cerqueira
    • 2
  • Maria M. Brooks
    • 3
  • Andrew D. Althouse
    • 3
  • Veronica V. Sansing
    • 3
  • George A. Beller
    • 4
  • Rodica Pop-Busui
    • 5
  • Raymond Taillefer
    • 6
  • Bernard R. Chaitman
    • 7
  • Raymond J. Gibbons
    • 8
  • Jaekyeong Heo
    • 9
  • Ami E. Iskandrian
    • 9
  1. 1.Emory Clinical Cardiovascular Research InstituteEmory University School of MedicineAtlantaUSA
  2. 2.Cleveland Clinic FoundationClevelandUSA
  3. 3.University of Pittsburgh School of Public HealthPittsburghUSA
  4. 4.University of VirginiaCharlottesvilleUSA
  5. 5.University of MichiganAnn ArborUSA
  6. 6.Montreal Heart InstituteMontrealCanada
  7. 7.Saint Louis University School of MedicineSt. LouisUSA
  8. 8.Mayo ClinicRochesterUSA
  9. 9.University of Alabama at BirminghamBirminghamUSA

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