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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

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Journal of Nuclear Cardiology Aims and scope

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.

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Authors and Affiliations

  1. Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, 1462 Clifton Rd NE, Room 529, Atlanta, GA, 30306, USA

    Leslee J. Shaw PhD

  2. Cleveland Clinic Foundation, Cleveland, OH, USA

    Manuel D. Cerqueira MD

  3. University of Pittsburgh School of Public Health, Pittsburgh, PA, USA

    Maria M. Brooks PhD, Andrew D. Althouse MA & Veronica V. Sansing MS, PhD

  4. University of Virginia, Charlottesville, VA, USA

    George A. Beller MD

  5. University of Michigan, Ann Arbor, MI, USA

    Rodica Pop-Busui MD, PhD

  6. Montreal Heart Institute, Montreal, QC, Canada

    Raymond Taillefer MD

  7. Saint Louis University School of Medicine, St. Louis, MO, USA

    Bernard R. Chaitman MD

  8. Mayo Clinic, Rochester, MN, USA

    Raymond J. Gibbons MD

  9. University of Alabama at Birmingham, Birmingham, AL, USA

    Jaekyeong Heo MD & Ami E. Iskandrian MD

Authors
  1. Leslee J. Shaw PhD
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  2. Manuel D. Cerqueira MD
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  3. Maria M. Brooks PhD
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  4. Andrew D. Althouse MA
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  5. Veronica V. Sansing MS, PhD
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  6. George A. Beller MD
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  7. Rodica Pop-Busui MD, PhD
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  8. Raymond Taillefer MD
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  9. Bernard R. Chaitman MD
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  11. Jaekyeong Heo MD
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  12. Ami E. Iskandrian MD
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Corresponding author

Correspondence to Leslee J. Shaw PhD.

Additional information

This study is conducted for the BARI 2D Investigators.

The Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) is funded by the National Heart, Lung and Blood Institute and the National Institute of Diabetes and Digestive and Kidney Diseases (U01 HL061744, U01 HL061746, U01 HL061748, U01 HL063804). BARI 2D receives significant supplemental funding from GlaxoSmithKline and additional funding from Lantheus Medical Imaging, Inc. (formerly Bristol-Myers Squibb Medical Imaging, Inc.), Astellas Pharma US, Inc., Merck & Co., Inc., Abbott Laboratories, Inc. and Pfizer, Inc. Medications and supplies were donated by Abbott Laboratories, Ltd., MediSense Products, Bayer Diagnostics, Becton, Dickinson, and company, J. R. Carlson Labs, Centocor, Inc., Eli Lilly and company, LipoScience, Inc., Merck Sante, Novartis Pharmaceuticals Corporation, and Novo Nordisk, Inc. Unrestricted grant support for the Nuclear Core Laboratory was provided by Astellas Healthcare and Lantheus Imaging.

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Shaw, L.J., Cerqueira, M.D., Brooks, M.M. et al. 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. J. Nucl. Cardiol. 19, 658–669 (2012). https://doi.org/10.1007/s12350-012-9548-3

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  • DOI: https://doi.org/10.1007/s12350-012-9548-3

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