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Invited Commentary
April 8, 2020

Percutaneous Coronary Intervention or Coronary Artery Bypass Grafting to Treat Ischemic Cardiomyopathy?

Author Affiliations
  • 1Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
JAMA Cardiol. Published online April 8, 2020. doi:10.1001/jamacardio.2020.0597

Discussions regarding whether and how best to revascularize patients who present with obstructive epicardial coronary artery disease and reduced left ventricular (LV) systolic function are daily occurrences in hospitals across the world. This is actually good news. An aging population, particularly in high-income countries, has reaped the benefits of atherosclerotic risk reduction treatments and guideline-directed medical therapies for heart failure with reduced ejection fraction (HFrEF), is surviving longer, and is increasingly at risk for ischemic cardiomyopathy. Unfortunately, the rise in cardiometabolic conditions is projected to fuel the prevalence of CAD and HFrEF among younger patients and lower-income countries. Although commonplace, these discussions on whether and how to revascularize patients with HFrEF occur less frequently than may be warranted,1 lead to substantial upstream noninvasive testing of questionable value,2 and are not optimally informed. In fact, the contemporary evidence available is limited. The Surgical Treatment for Ischemic Heart Failure (STICH) trial randomized 1212 patients with ischemic cardiomyopathy from 2002 to 2007 to receive optimal medical therapy with or without coronary artery bypass grafting surgery (CABG) and represents what to our knowledge is the largest randomized experience in such patients.3 These results defined the benefits of surgical revascularization; however, percutaneous coronary intervention (PCI) was not evaluated in STICH. While PCI and CABG procedures are among the most common in medicine, the role of PCI compared with either medical therapy alone or against CABG is markedly understudied in patients with LV dysfunction, as the numbers of such patients included in randomized PCI trials is miniscule. What to our knowledge is the first trial comparing PCI with medical therapy in such patients is still underway.4 As such, the accompanying observational comparative effectiveness cohort study by Sun and colleagues5 in this issue of JAMA Cardiology is not only welcome but actionable.