Department of Cardiology, Castle Hill Hospital, University of Hull, Kingston upon Hull HU16 5JQ, UK.
Eur J Heart Fail. 2011 Feb;13(2):227-33. doi: 10.1093/eurjhf/hfq230. Epub 2010 Dec 13.
Revascularization is frequently advocated to improve ventricular function and prognosis for patients with heart failure due to coronary artery disease, especially when there is evidence of extensive myocardial viability.
Patients with heart failure, coronary artery disease, and a left ventricular (LV) ejection fraction < 35%, who had a substantial volume of viable myocardium with contractile dysfunction assessed by any standard imaging technique, were randomly assigned to a strategy of conservative management vs. angiography with the intent of percutaneous or surgical revascularization. Patients requiring revascularization for angina or too frail for surgery were excluded. Only 138 of the planned 800 patients were enrolled because of withdrawal of funding due to slow recruitment. Also, a larger trial (The Surgical Treatment for Ischemic Heart Failure Trial) addressing a similar question became available, which investigators were encouraged to join. Of 69 patients assigned to the invasive strategy, 6 refused angiography, 2 died as a result of the diagnostic procedure, 14 were considered unsuitable for revascularization, 2 refused surgery, and 45 had revascularization. After a median follow-up of 59 (inter-quartile range: 33-63) months, there were 51 (37%) deaths; 25 (37%) in those assigned to the conservative strategy, and 26 (38%) in those assigned to the invasive strategy, 13 (29%) of whom had been revascularized.
A conservative management strategy may not be inferior to one of coronary arteriography with the intent to revascularize in patients with heart failure, LV systolic dysfunction, and extensive myocardial viability. However, this study was underpowered and, further, larger trials are required to settle this issue. Clinical trials Registration No: ISRCTN86284615.
对于因冠状动脉疾病而导致心力衰竭的患者，通常提倡血运重建以改善心室功能和预后，尤其是当存在广泛心肌存活证据时。
患有心力衰竭、冠状动脉疾病和左心室（LV）射血分数<35%的患者，通过任何标准成像技术评估存在大量收缩功能障碍的存活心肌且具有可观的容积，这些患者被随机分配至保守治疗策略与血管造影策略，以实现经皮或手术血运重建。排除因心绞痛需要血运重建或因身体太虚弱而不能接受手术的患者。由于募集缓慢，原计划招募 800 名患者中只有 138 名患者入组。此外，一项类似问题的大型试验（缺血性心力衰竭的手术治疗试验）可用，鼓励研究人员加入该试验。在 69 名被分配到有创策略的患者中，有 6 名拒绝了血管造影，2 名因诊断程序而死亡，14 名被认为不适合血运重建，2 名拒绝手术，45 名患者进行了血运重建。在中位数为 59（四分位距：33-63）个月的随访后，有 51 名（37%）患者死亡；在保守治疗策略组中有 25 名（37%）患者死亡，在有创治疗策略组中有 26 名（38%）患者死亡，其中 13 名（29%）患者进行了血运重建。
对于心力衰竭、LV 收缩功能障碍和广泛心肌存活的患者，与血管造影并意图血运重建的保守治疗策略相比，可能并不差。然而，本研究的效力不足，需要进行更大规模的试验来解决这一问题。临床试验注册号：ISRCTN86284615。
