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Impact of left ventricular function and the extent of ischemia and scar by stress myocardial perfusion imaging on prognosis and therapeutic risk reduction in diabetic patients with coronary artery disease: results from the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial.

BACKGROUND: The Bypass Angioplasty Revascularization Investigation 2 Diabetes trial demonstrated similar long-term clinical effectiveness of revascularization (REV) and intensive medical (MED) therapy. Comparisons of post-intervention ischemic burden have not been explored but are relevant to treatment decisions. This study examined differences in 1-year stress myocardial perfusion SPECT (MPS) abnormalities by randomized treatment. METHODS: MPS was performed in 1,505 patients at 1-year following randomization. MPS images were analyzed (masked to treatment) by a Nuclear Core Laboratory using a quantitative percent (%) of total, ischemic, and scarred myocardium. Cox proportional hazards models were used to estimate the relationship between MPS variables and trial endpoints. RESULTS: At 1-year, nearly all REV patients underwent the assigned procedure; while 16% of those randomized to MED received coronary REV. Patients randomized to REV exhibited fewer stress perfusion abnormalities than MED patients (P < .001). CABG patients had more frequent ischemic and scarred myocardium encumbering ≥ 5% of the myocardium when compared to those receiving PCI. Patients randomized to MED had more extensive ischemia and the median % of the myocardium with perfusion abnormalities was lower following REV (3% vs 9%, P = .01). A total of 59% of REV patients had no inducible ischemia at 1-year compared to 49% of MED patients (P < .001). Within the CABG stratum, those randomized to MED had the greatest rate of ischemic (P = .032) and scarred (P = .017) perfusion abnormalities. At 1-year, more extensive and severe stress myocardial perfusion abnormalities were associated with higher 5-year rates of death and a combined endpoint of cardiac death or myocardial infarction (MI) rates (11.3%, 8.1%, 6.8%, for ≥ 10%, 5%-9.9%, and 1-4.9% abnormal myocardium at stress, respectively, P < .001). In adjusted models, selected MPS variables were significantly associated with an increased hazard of cardiac death or MI (hazard ratio = 1.11 per 5% increase in abnormal myocardium at stress, P = .004). CONCLUSIONS: Patient management strategies that focus on ischemia resolution can be useful to guide the efficacy of near-term therapeutic approaches. A 1-year post-therapeutic intervention myocardial perfusion scan provides important information regarding prognosis in stable CAD patients with diabetes.

Pubmed ID: 22527794

Authors

  • Shaw LJ
  • Cerqueira MD
  • Brooks MM
  • Althouse AD
  • Sansing VV
  • Beller GA
  • Pop-Busui R
  • Taillefer R
  • Chaitman BR
  • Gibbons RJ
  • Heo J
  • Iskandrian AE

Journal

Journal of nuclear cardiology : official publication of the American Society of Nuclear Cardiology

Publication Data

August 13, 2012

Associated Grants

  • Agency: NHLBI NIH HHS, Id: R01 HL102334
  • Agency: NHLBI NIH HHS, Id: U01 HL061744
  • Agency: NHLBI NIH HHS, Id: U01 HL061744
  • Agency: NHLBI NIH HHS, Id: U01 HL061746
  • Agency: NHLBI NIH HHS, Id: U01 HL061746
  • Agency: NHLBI NIH HHS, Id: U01 HL061748
  • Agency: NHLBI NIH HHS, Id: U01 HL061748
  • Agency: NHLBI NIH HHS, Id: U01 HL063804

Mesh Terms

  • Aged
  • Angioplasty, Balloon, Coronary
  • Cicatrix
  • Coronary Disease
  • Diabetes Complications
  • Diabetes Mellitus
  • Female
  • Humans
  • Male
  • Middle Aged
  • Myocardial Ischemia
  • Myocardial Perfusion Imaging
  • Myocardium
  • Prognosis
  • Proportional Hazards Models
  • Risk
  • Tomography, Emission-Computed, Single-Photon
  • Ventricular Function, Left