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Journal of Nuclear Cardiology

, Volume 13, Issue 6, pp 768–778 | Cite as

Predicting therapeutic benefit from myocardial revascularization procedures: Are measurements of both resting left ventricular ejection fraction and stress-induced myocardial ischemia necessary?

  • Rory Hachamovitch
  • Alan Rozanski
  • Sean W. Hayes
  • Louise E. J. Thomson
  • Guido Germano
  • John D. Friedman
  • Ishac Cohen
  • Daniel S. BermanEmail author
Article

Abstract

Background

We hypothesized that ejection fraction (EF) best predicts cardiovascular death but only measures of ischemia predict relative survival benefit from revascularization compared with medical therapy.

Methods and Result

We followed up 5366 consecutive patients without prior revascularization who underwent stress electrocardiography-gated myocardial perfusion single photon emission computed tomography (MPS) for 2.8 ± 1.2 years, during which 146 cardiac deaths occurred (2.7%, 1.0%/y). The treatment received within 60 days after MPS was used to define the subgroups (revascularization in 402 patients, with cardiac death occurring in 6.2%, vs medical therapy in 4964 patients, with cardiac death occurring in 2.4%; P < .0001, χ2 = 18.7). Adjustment for nonrandomized treatment assignment used a propensity score based on logistic regression modeling of referral to revascularization. The percent of myocardium that was ischemic was the most important predictor of revascularization. The overall model (multivariate χ2 = 728, c index = 0.89, P < 10-5) was used as a propensity score. Cox proportional hazards analysis, assessing the relationship between MPS results, non-MPS covariates, and cardiac death, revealed that EF was superior to percent ischemic myocardium in the prediction of cardiac death after adjustment for pre-MPS data and the propensity score. However, an interaction between percent ischemic myocardium and revascularization was present such that, irrespective of EF, patients with little or no ischemia had an improved survival rate with medical therapy, whereas with increasing ischemia, progressive improvements in survival rate were noted with revascularization.

Conclusions

Although EF predicts cardiac death, only inducible ischemia identifies which patients have a short-term benefit from revascularization.

Key Words

Technetium 99m sestamibi single photon emission computed tomography myocardial perfusion prognosis outcomes 

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Copyright information

© American Society of Nuclear Cardiology 2006

Authors and Affiliations

  • Rory Hachamovitch
    • 1
  • Alan Rozanski
    • 2
  • Sean W. Hayes
    • 3
  • Louise E. J. Thomson
    • 3
  • Guido Germano
    • 3
    • 4
  • John D. Friedman
    • 3
    • 4
  • Ishac Cohen
    • 3
    • 4
  • Daniel S. Berman
    • 3
    • 4
    Email author
  1. 1.Cardiovascular Division, Department of Medicine, Keck School of MedicineUniversity of Southern CaliforniaLos AngelesCalif
  2. 2.Division of Cardiology, Department of MedicineSt Luke’s Roosevelt Hospital Center, College of Physicians and Surgeons, Columbia UniversityNew York
  3. 3.Departments of Imaging (Division of Nuclear Medicine) and Medicine (Division of Cardiology)Cedars-Sinai Medical CenterLos Angeles
  4. 4.Department of Medicine, School of MedicineUniversity of California, Los AngelesLos AngelesCalif

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