Gasior Pawel, Wojakowski Wojciech, Kedhi Elvin
Division of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland.
Erasmus Hospital, Université libre de Bruxelles (ULB), Brussels, Belgium.
Curr Cardiol Rep. 2023 May;25(5):401-409. doi: 10.1007/s11886-023-01860-3. Epub 2023 Apr 3.
Coronary artery disease (CAD) is estimated to account for over 60% of heart failure (HF) patients and is associated with worse outcomes than a non-ischemic etiology. In patients with ischemic HF, myocardial revascularization has multiple mechanisms of action based on the concept that blood flow restoration of viable but underperfused myocardium might reverse the hibernation of the left ventricle and prevent future spontaneous myocardial infarction, which could potentially improve patients' outcomes. Here, we aim to elaborate on indications, timing, type, and impact of completeness of revascularization in patients with heart failure with reduced ejection fraction (HFrEF) and ischemic etiology.
For decades, coronary artery bypass graft surgery has been the pilar of revascularization in patents with multivessel CAD and reduced EF. Recent development in the interventional field led to overall increase of percutaneous coronary intervention (PCI) adoption in treatment of ischemic HFrEF. However, recently published randomized study demonstrated no added benefit of PCI over optimal medical therapy in patients with severe ischemic cardiomyopathy challenging the beneficial role of revascularization in this setting. Since the decision on revascularization in ischemic cardiomyopathy frequently cannot be made based strictly on guidelines, tailored treatment strategy should be mandated with the essential role of multidisciplinary approach. These decisions should be based on capability to achieve complete revascularization, with the consideration that in certain situations it may not be accomplished.
据估计，冠心病（CAD）占心力衰竭（HF）患者的60%以上，且与非缺血性病因相比，其预后更差。在缺血性HF患者中，心肌血运重建具有多种作用机制，其基于这样的概念，即恢复存活但灌注不足心肌的血流可能会逆转左心室的冬眠状态，并预防未来的自发性心肌梗死，这可能会改善患者的预后。在此，我们旨在详细阐述射血分数降低的心力衰竭（HFrEF）且病因是缺血性的患者血运重建的适应症、时机、类型及血运重建完整性的影响。
几十年来，冠状动脉旁路移植术一直是多支血管CAD且射血分数降低患者血运重建的支柱。介入领域的最新进展导致经皮冠状动脉介入治疗（PCI）在缺血性HFrEF治疗中的应用总体增加。然而，最近发表的一项随机研究表明，在严重缺血性心肌病患者中，PCI相对于最佳药物治疗并无额外益处，这对这种情况下血运重建的有益作用提出了挑战。由于缺血性心肌病血运重建的决策往往不能严格依据指南做出，因此应采用多学科方法发挥关键作用的量身定制的治疗策略。这些决策应基于实现完全血运重建的能力，并考虑到在某些情况下可能无法实现这一点。
