To Stent or Not to Stent in Ischemic Heart Failure

The question of revascularization in patients with heart failure (HF) and severe left ventricular (LV) systolic dysfunction is almost as old as the specialty itself.^[1] The STICH (Surgical Treatment for Ischemic Heart Failure) trial did not demonstrate a survival benefit of coronary artery bypass grafting at 5 years in patients with ischemic cardiomyopathy (ICM).^[2] Percutaneous coronary intervention (PCI) has not been studied in patients with severe LV dysfunction. The REVIVED-BCIS2 (Revascularization for Ischemic Ventricular Dysfunction) compared PCI with optimal medical therapy (OMT) in patients with severe
ICM.^[3]

The REVIVED-BCIS2 was a prospective, multicenter, randomized, open-label trial involving 700 patients. Inclusion criteria were left ventricular ejection fraction (LVEF) <35%, extensive coronary artery disease (CAD; defined as British Cardiovascular Intervention Society [BCIS] jeopardy score >6), and viability in at least four dysfunctional myocardial segments amenable to revascularization. Patients were randomized to PCI plus OMT or to OMT alone (individually adjusted pharmacologic and device therapy for HF). The primary outcome was death from any cause or hospitalization for HF over a minimum of 24 months.

The primary outcome was not different between the PCI-plus-OMT and OMT-alone groups (37.2% vs. 38%). The findings remained unchanged across all subgroups, including patients with diabetes mellitus and those with left main artery disease. Improved quality of life (QoL) as assessed by Kansas City Cardiomyopathy Questionnaire scores was observed in the PCI-plus-OMT group, but this improvement never reached statistical significance. LVEF improved in both groups without significant difference.

In summary, PCI did not improve clinical outcomes in patients with HF, severe CAD, and myocardial viability. Most patients in the trial had little to no angina, so the lack of benefit in QoL cannot be extrapolated to patients with those symptoms or to patients with acute coronary syndromes. This trial, like many others, highlights the paramount importance of OMT in patients with HF. The optimal role of revascularization remains to be determined.

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