Treatment Plan for Patient with CAD, Reduced EF, and Peri-Infarct Ischemia
Coronary artery bypass grafting (CABG) is recommended as the optimal treatment for this patient with severe LV dysfunction (EF 30-35%), heart failure, and significant coronary artery disease with evidence of peri-infarct ischemia. 1
Assessment of Current Status
The patient presents with:
- Moderate-sized perfusion abnormality on SPECT imaging with evidence of peri-infarct ischemia
- Severely reduced ejection fraction (30-35%)
- Grade II diastolic dysfunction
- History of previous CABG (24 years ago)
- Recent left heart catheterization (2023)
Treatment Algorithm
Step 1: Evaluation for Revascularization
- The patient has clear evidence of ischemia on stress imaging with a severely reduced EF of 30-35%
- According to guidelines, CABG or medical therapy is reasonable to improve morbidity and mortality for patients with severe LV dysfunction (EF <35%), heart failure, and significant CAD (Class IIa, Level of Evidence B) 1
- The presence of peri-infarct ischemia indicates viable myocardium that could benefit from revascularization
Step 2: Heart Team Consultation
- Referral to a Heart Team is essential for this complex case with prior CABG
- The Heart Team should evaluate:
- Coronary anatomy from recent LHC (2023)
- Graft patency status
- Technical feasibility of repeat CABG vs. PCI
- Surgical risk assessment
Step 3: Medical Therapy Optimization
While preparing for potential revascularization, optimize guideline-directed medical therapy (GDMT):
- High-intensity statin therapy (e.g., atorvastatin 80 mg daily) 2
- Beta-blocker titrated to maximum tolerated dose
- ACE inhibitor or ARB titrated to maximum tolerated dose
- Consider aldosterone antagonist (given EF <35%)
- Antiplatelet therapy
Step 4: Revascularization Decision
Based on the patient's profile with:
- EF ≤35%
- Evidence of peri-infarct ischemia
- Prior CABG (24 years ago)
The 2023 AHA/ACC guidelines and 2013 ACCF/AHA guidelines support revascularization in this scenario 1:
- If surgical risk is acceptable: CABG is preferred (Class IIa recommendation)
- If high surgical risk: PCI may be considered as an alternative (Class IIb recommendation) 1
Evidence Supporting This Approach
The STICH trial demonstrated that in patients with EF ≤35% and coronary disease amenable to CABG, surgical revascularization resulted in lower cardiovascular death (33% vs. 28%; p=0.05) and lower all-cause death or cardiovascular hospitalization (68% vs. 58%; p<0.001) compared to medical therapy alone 1.
A secondary analysis of the ISCHEMIA trial showed that in participants with heart failure or LVEF <45%, both the 4-year primary composite endpoint and cardiovascular death or MI were significantly lower in the invasive treatment arm 1.
Important Considerations and Pitfalls
Timing of previous CABG: With the patient's CABG performed 24 years ago, graft failure is likely. The recent LHC (2023) results should be carefully reviewed to assess graft patency.
Surgical risk assessment: Given the patient's reduced EF, careful evaluation of surgical risk is essential. Tools like the STS score should be used to estimate perioperative risk.
Completeness of revascularization: If PCI is chosen, aim for complete ischemic revascularization rather than just anatomic revascularization.
GDMT adherence: Regardless of revascularization strategy, adherence to GDMT is independently associated with reduced mortality in patients with CAD and HFrEF 3.
Avoid delay: The presence of peri-infarct ischemia indicates viable myocardium at risk, which should be addressed promptly to prevent further deterioration of ventricular function.
This treatment approach prioritizes mortality reduction and quality of life improvement through addressing the underlying ischemia while optimizing medical therapy for heart failure with reduced ejection fraction.