Impact of Chronic Total Occlusion of the Coronary Artery on Long-Term Prognosis in Patients With Ischemic Systolic Heart Failure
abstract
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Access this abstract now Full Text Available for ClinicalKey SubscribersOBJECTIVES
This study sought to assess the impact of chronic total occlusion (CTO) on long-term prognosis in patients with ischemic cardiomyopathy.
BACKGROUND
The presence of concomitant CTO in a nonculprit lesion in acute coronary syndromes is associated with worse prognosis. Coronary artery disease is the main cause of heart failure and in many cases at least 1 CTO is observed.
METHODS
The study included all patients with systolic heart failure who underwent elective coronary angiography and were registered from January 2009 to December 2014 in the ongoing single-center COMMIT-HF (COnteMporary Modalities In Treatment of Heart Failure) registry (NCT02536443). The patients were divided into 2 groups with regard to CTO presence. All of the analyzed patients were followed up for at least 12 months with all-cause mortality defined as the primary endpoint.
RESULTS
Of the 675 patients fulfilling the inclusion and exclusion criteria, 278 patients (41.2%) had 1 or more CTOs of a major coronary artery (+CTO), and in 397 patients (58.8%) the presence of the CTO was not observed (-CTO). The 12-month mortality for the +CTO and -CTO patients was 19.4 % and 10.3 %, respectively (p < 0.001), evident also after 24 months (26.6% vs. 17.6%; p = 0.01). After a multivariate adjustment for differences in baseline characteristics, the presence of CTO remained significantly associated with higher 12-month mortality (relative risk: 1.84: 95% confidence interval: 1.18 to 2.85; p = 0.006).
CONCLUSIONS
Our analysis showed that in patients with ischemic heart failure the presence of the CTO is related to worse long-term prognosis.
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Additional Info
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Impact of Chronic Total Occlusion of the Coronary Artery on Long-Term Prognosis in Patients With Ischemic Systolic Heart Failure: Insights From the COMMIT-HF Registry
JACC Cardiovasc Interv 2016 Sep 12;9(17)1790-1797, M Tajstra, Ł Pyka, J Gorol, D Pres, M Gierlotka, E Gadula-Gacek, A Kurek, M Wasiak, M Hawranek, MO Zembala, A Lekston, L Poloński, L Bryniarski, M GąsiorFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
The study by Tajstra et al tells us that almost half (41.2%) of patients with systolic heart failure also have a chronic total occlusion (CTO) and those who have a CTO have significantly higher mortality over the ensuing 2 years, even after multivariable adjustment. There are several potential explanations for this finding, including the worse clinical profile of CTO patients and the association of CTO with incomplete revascularization (leading to more extensive ischemia and worse left ventricular function), electrical instability, reduced exercise capacity due to symptoms, and poorer quality of life (more limitations to daily activities, possibly more depression).
The present study does not and cannot answer whether CTO revascularization could improve subsequent clinical outcomes. Although mechanistically plausible, this question needs to be explored in a properly performed prospective, randomized-controlled trial. The EXPLORE trial (presented at the TCT 2015 meeting) did not show improvement in left ventricular ejection fraction after 4 months with CTO PCI in patients who had primary PCI for ST-segment elevation acute myocardial infarction and were also found to have a CTO. However, CTO PCI success rates were relatively low, and improvement was observed in left anterior descending artery CTOs.
At the present time, interventional cardiologists should use the patient’s symptoms and extent of ischemia to guide clinical decision-making in patients with coronary CTOs: CTO revascularization (with PCI or coronary bypass graft surgery) should generally be offered to patients with significant symptoms despite optimal medical therapy and/or significant ischemia, provided that the potential risks do not outweigh the anticipated benefits.