Myocardial viability for decision-making concerning revascularization in patients with left ventricular dysfunction and coronary artery disease: A meta-analysis of non-randomized and randomized studies

doi:10.1016/j.ijcard.2015.01.025

International Journal of Cardiology

Volume 182, 1 March 2015, Pages 494-499

https://doi.org/10.1016/j.ijcard.2015.01.025 Get rights and content

Abstract

Background

Myocardial viability tests have been proposed as a key factor in the decision-making process concerning coronary revascularization procedures in patients with left ventricular dysfunction and coronary artery disease (LVD–CAD).

Methods

We performed a systematic review and meta-analysis of studies that compared medical treatment with revascularization in patients with viable and non-viable myocardium and recorded mortality as outcome.

Results

Thirty-two non-randomized (4328 patients) and 4 randomized (1079 patients) studies were analyzed. In non-randomized studies, revascularization provided a significant mortality benefit compared with medical treatment (p < 0.05). Since the heterogeneity was significant (p < 0.05) a viability subgroup analysis was performed, showing that revascularization provided a significant mortality benefit compared with medical treatment in patients with viable myocardium (p < 0.05) but not in patients without (p = 0.34). There was a significant subgroup effect (p < 0.05) related to the intensity of the effect, but not to the direction. In randomized studies, revascularization did not provide a significant mortality benefit compared with medical treatment in either patients with viable myocardium or those without (p = 0.21). There was no significant subgroup effect (p = 0.72). Neither non-randomized nor randomized studies demonstrated any significant difference in outcomes between patients with and without viable myocardium.

Conclusions

The available data are inconclusive regarding the usefulness of myocardial viability tests for the decision-making process concerning revascularization in LVD–CAD patients.

Patients with viable myocardium appear to benefit from revascularization, but similar benefits were observed in patients without viable myocardium. Moreover, a neutral or adverse effect of revascularization cannot be excluded in either group of patients.

Introduction

Since 1982, when Rahimtoola [1] first described the recovery of ventricular function after revascularization in patients with left ventricular dysfunction and coronary artery disease (LVD–CAD), our interest in myocardial viability has progressed from determining its pathophysiology, to its diagnostic potential, and finally to its usefulness in the clinical setting.

After the concept of hibernating myocardium was introduced [2], numerous techniques were developed for evaluating its presence or absence in patients with LVD–CAD or previous myocardial infarction (MI).

Once myocardial viability could be diagnosed with acceptable accuracy [3], the next step was to establish whether its presence or absence could guide clinical practice. The prognosis of patients with LVD–CAD is strongly related to the ejection fraction (EF) [4]. Consequently, the hypothesis was that if patients have viable myocardium, revascularization can improve heart function and therefore survival; otherwise, patients will do better with medical therapy alone.

The cardiovascular community adopted this premise as true, and myocardial viability tests gained a key place in the decision-making process concerning myocardial revascularization in patients with LVD–CAD. However, the published literature on this matter remains unclear and controversial. Accordingly, we performed a systematic review and meta-analysis of studies that compared medical treatment with revascularization in patients with viable and non-viable myocardium.

Section snippets

Literature search

The MEDLINE database was searched using PubMed to retrieve publications from between January 1960 and July 2013. Studies were selected if they: (1) included patients with LVD–CAD and/or previous MI, (2) tested myocardial viability, (3) compared medical treatment and revascularization in patients with viable myocardium and/or in patients without viable myocardium, and (4) recorded cardiac death or all-cause mortality as outcomes. Previous meta-analyses and systematic reviews were also analyzed

Studies and patients

The database search identified 389 potentially relevant citations; 30 additional articles were included from references (Fig. 1). On the basis of their title and abstract, 101 studies were retrieved as complete reports, of which 36 met the eligibility criteria.

We included 32 non-randomized studies [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39], [40] (4328

Discussion

In non-randomized studies, the revascularization procedures were associated with a significant reduction in mortality, regardless of the presence of viable myocardium. Although the heterogeneity test results between groups with and without viability were statistically significant, the difference was quantitative (different amount of benefit) and not qualitative (different direction of the effect). When only non-randomized studies were considered, it seemed as if all the patients could

Conclusions

The available data are not conclusive regarding the usefulness of myocardial viability tests in the decision-making process concerning revascularization in patients with LVD–CAD. Patients with viable myocardium appear to benefit from revascularization, but the same benefits were observed in patients without viable myocardium. Moreover, a neutral or adverse effect of revascularization cannot be excluded in either group of patients.

A randomized clinical trial with an adequate number of patients,

Sources of funding

The study was performed by the ECLA Foundation with no external source of funding.

Conflict of interest

The authors declare no conflict of interest.

Acknowledgment

The authors thank all ECLA Foundation personnel for technical assistance with the manuscript.

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¹: All the authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

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Myocardial viability for decision-making concerning revascularization in patients with left ventricular dysfunction and coronary artery disease: A meta-analysis of non-randomized and randomized studies

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Literature search

Studies and patients

Discussion

Conclusions

Sources of funding

Conflict of interest

Acknowledgment

J. Am. Coll. Cardiol.

J. Am. Coll. Cardiol.

J. Am. Coll. Cardiol.

J. Nucl. Cardiol.

J. Am. Coll. Cardiol.

J. Am. Coll. Cardiol.

Am. J. Cardiol.

J. Am. Coll. Cardiol.

Am. J. Cardiol.

J. Thorac. Cardiovasc. Surg.

J. Am. Coll. Cardiol.

Chest

J. Am. Coll. Cardiol.

J. Am. Coll. Cardiol.

J. Am. Coll. Cardiol.

Am. J. Cardiol.

J. Nucl. Cardiol.

Am. J. Cardiol.

Am. J. Cardiol.

Am. J. Cardiol.

J. Am. Coll. Cardiol.

Rev. Esp. Med. Nucl.

Am. Heart J.