Myocardial revascularization reverses adverse outcome in non-ST-elevation acute coronary syndromes complicated by heart failure.

BACKGROUND

Congestive heart failure (CHF) has a strong negative prognostic impact in patients with non-ST-elevation acute coronary syndromes (NSTE-ACS). The purpose of this study was to establish the effect of myocardial revascularization on prognosis in this setting.

METHODS

We retrospectively studied 648 patients admitted with NSTE-ACS and not presenting cardiogenic shock. The effect of coronary revascularization on the outcome of patients with and without CHF was assessed using a propensity score-adjusted regression model.

RESULTS

Congestive heart failure was present in 89 patients (14.5%) on hospital admission. During the index hospitalization, 426 patients received myocardial revascularization, through percutaneous coronary intervention (PCI) in 321 cases, and coronary artery bypass grafting (CABG) in 105. In a 6-month follow-up, 38 patients (6.2%) died and 42 (6.8%) experienced non-fatal myocardial infarction (MI). CHF was an independent predictor of both 6-month mortality (adjusted HR 3.6; 95% CI 1.86-6.95; p < 0.001) and 6-month death/(re-)MI (adjusted HR 2.1; 95% CI 1.3-3.5; p = 0.003). Revascularization significantly influenced the prognosis of patients presenting CHF (adjusted HR 0.31; 95% CI 0.13-0.73; p = 0.008), but not of those without CHF (adjusted HR 1.37; 95% CI 0.65-2.89; p = 0.4). A significant interaction was found between revascularization and the prognostic impact of CHF at admission (p = 0.021 for the interaction).

CONCLUSIONS

In patients with NSTE-ACS, clinical manifestations of CHF constitute a strong predictor of adverse medium-term outcome that may be significantly modified by myocardial revascularization.