Optimal medical therapy vs. revascularization on long-term LV function

Abstract

This editorial refers to ‘Long-term analysis of left ventricular ejection fraction in patients with stable multivessel coronary disease undergoing medicine, angioplasty, or surgery: 10-year follow-up of the MASS II trial’, by C.L. Garzillo et al. , doi:10.1093/eurheartj/eht201 The optimal strategy for the management of patients with stable ischaemic heart disease (SIHD) has been a matter of considerable debate over the past two decades. Without question, during this time period, there have been profound technological evolutions in revascularization (both catheter based and surgical) as well as the development of increasingly effective pharmacological therapies, notably the class of agents that are widely regarded as disease-modifying interventions (statins, inhibitors of the renin–angiotensin–aldosterone system, and thienopyridines), as well as more time-honoured treatments such as aspirin and anti-ischaemic agents (beta-blockers, calcium antagonists, nitrates, ranolazine, and ivabradine). Against this backdrop of improving pharmacological approaches, clinicians who care for patients with SIHD frequently confront the decision of whether the initial management should be optimal medical therapy (OMT) alone, or OMT combined with revascularization.1 When revascularization is considered, both coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI) are potential options. In general, certain core diagnostic principles guide therapeutic decision-making as to the best treatment options that need to be individualized. In general, these include the patient's clinical presentation, the severity and magnitude of ischaemia, the extent and distribution of coronary anatomic disease, and the presence of both cardiac and non-cardiac medical conditions and co-morbidities. One of the core tenets of management has been the premise that revascularization directed at flow-limiting coronary stenoses will more effectively treat regional myocardial ischaemia and, in turn, will preserve left ventricular (LV) ejection fraction (EF). Clearly, primary PCI for acute ST-segment elevation myocardial infarction (MI) improves both clinical outcomes and LVEF.2 Whether revascularization imparts similar, salutary outcomes in SIHD …