How can we detect the low risk patients for ischemic etiology in heart failure population?

Abstract

In the recent issue of your journal I have read the article by Silva et al. with great interest [ [1] Silva F. Borges T. Ribeiro A. et al. Heart failure with reduced ejection fraction: should we submit patients without angina to coronary angiography?. Int. J. Cardiol. 2015; 190: 131-132 Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar ]. In their study, the authors reported that patients with heart failure with reduced ejection fraction (HFREF) and without angina and risk factors had high prevalence of angiographically significant coronary artery disease (CAD) and they suggested performance of routine coronary angiography (CA) in HFREF patients. It is known that CAD is the most common etiology in patients with heart failure [ [2] Fox K.F. Cowie M.R. Wood D.A. et al. Coronary artery disease as the cause of incident heart failure in the population. Eur. Heart J. 2001; 22: 228-236 Crossref PubMed Scopus (300) Google Scholar ]. In this paper, I would like to emphasize some confusing factors and possible overestimated incidence of CAD in patients with HFREF without angina and risk factors. In the present study of Silva et al., the authors suggested that the predictors of CAD as angina and conventional risk factors are mostly accepted. In a recent study, it has been reported that incidence of chest pain was not significantly different in HFREF patients who have coronary artery stenosis or not [ [3] Kosuga T. Komukai K. Miyanaga S. et al. Diabetes is a predictor of coronary artery stenosis in patients hospitalized with heart failure. Heart Vessels. Mar 31 2015; (Epub ahead of print) PubMed Google Scholar ]. Hence, it may be inappropriate to suggest the performance of routine CA by angina alone. In the present study, echocardiography has been performed to all patients. But, there is not another echocardiographic data except left ventricle ejection fraction. Echocardiography is one of the most sensitive techniques for detecting regional wall abnormalities [ [4] Feigenbaum H. Corya B.C. Dillon J.C. et al. Role of echocardiography in patients with coronary artery disease. Am. J. Cardiol. 1976; 37: 775-786 Abstract Full Text PDF PubMed Scopus (39) Google Scholar ]. To determine the akinetic, hypokinetic or dyskinetic wall segments may be useful to patients selection for performing CA, in addition to angina and risk factors. The authors should comment on the presence or absence of regional wall motion abnormalities in both patient groups and compare the groups regarding their wall motion score index, and akinetic, hypokinetic and dyskinetic wall segments. In HFERF patients, the presence of regional wall motion abnormalities may be a significant indicator of CAD. Therefore, it may affect the results of the present study of Silva et al. and the presence of higher levels of wall motion score indexes may overestimate the incidence of CAD in HFERF patients without angina and risk factors. In this sense, it may be a wrong approach to include these patients into the low risk patient group for ischemic etiology. Additionally, a novel echocardiographic calcification scores was found to be an independent indicator of significant CAD in a recent study [ [5] Hirschberg K. Reinhart M. Konstandin M. et al. Diagnostic and prognostic value of a novel cardiac calcification score for coronary artery disease by transthoracic echocardiography. Int. J. Cardiol. 2015; 190: 332-334 Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar ], and it may be useful to identify low risk HFREF patients for ischemic etiology who may benefit from CA and revascularization.