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Letter by Correia et al Regarding Article, “Stress Cardiac Magnetic Resonance Imaging Provides Effective Cardiac Risk Reclassification in Patients With Known or Suspected Stable Coronary Artery Disease”
2014; Lippincott Williams & Wilkins; Volume: 129; Issue: 15 Linguagem: Inglês
10.1161/circulationaha.113.005797
ISSN1524-4539
AutoresLuís Cláudio Lemos Correia, Márcia Noya-Rabelo, José Augusto Barreto‐Filho,
Tópico(s)Advanced MRI Techniques and Applications
ResumoHomeCirculationVol. 129, No. 15Letter by Correia et al Regarding Article, "Stress Cardiac Magnetic Resonance Imaging Provides Effective Cardiac Risk Reclassification in Patients With Known or Suspected Stable Coronary Artery Disease" Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by Correia et al Regarding Article, "Stress Cardiac Magnetic Resonance Imaging Provides Effective Cardiac Risk Reclassification in Patients With Known or Suspected Stable Coronary Artery Disease" Luis C.L. Correia, MD, PhD and Márcia M. Noya-Rabelo, MD, MSc José Augusto Barreto-Filho, MD, PhD Luis C.L. CorreiaLuis C.L. Correia Medical School of Bahia, Salvador, Brazil and Márcia M. Noya-RabeloMárcia M. Noya-Rabelo Medical School of Bahia, Salvador, Brazil José Augusto Barreto-FilhoJosé Augusto Barreto-Filho Federal University of Sergipe, Aracaju, Brazil Originally published15 Apr 2014https://doi.org/10.1161/CIRCULATIONAHA.113.005797Circulation. 2014;129:e450To the Editor:In a cohort of individuals with known or suspected stable coronary disease, Shah et al1 demonstrated that the presence and extent of myocardial ischemia, measured by stress cardiac magnetic resonance imaging perfusion, provide prognostic value over and above clinical features. We congratulate the authors on this work, and we agree with this conclusion. However, on the basis of the interaction between the prognostic value of ischemia and revascularization performed in only 76 patients, they concluded that the "knowledge of extent of ischemia provided to clinicians guiding their decisions to perform early coronary revascularization may have altered patient outlook."We believe that this speculation about the effects of early coronary revascularization on improving patient outcomes is not supported by their data. Moreover, it is misleading and may misguide clinicians to promote revascularization procedures on the basis of the ischemic score, independently of the clinical scenario. The observational nature of the study makes the finding of positive interaction vulnerable to confounding. The absence of randomization makes patients revascularized different from those not revascularized. Possibly, patients with severe ischemia who are not revascularized have clinical characteristics that prevented physicians to intervene. Maybe these comorbidities, not the ischemia per se, led to a worse prognosis. This might be a good example of confounding bias. In fact, the authors acknowledge this possibility: "Whether CMR [cardiac magnetic resonance] decision making in utilizing an invasive approach in addition to medical therapy requires prospective evaluation." However, prospective trials that randomly compared intervention and clinical treatment have already tested this hypothesis, and all have been negative. First, a substudy of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial demonstrated no beneficial effect of percutaneous coronary intervention regardless of whether patients had moderate to severe ischemia or no to mild ischemia by single-photon emission computed tomography.2 Similarly, the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial showed no interaction between the percent of ischemia and the efficacy of percutaneous coronary intervention.3 Third, in the Fractional Flow Reserve Versus Angiography for Multivessel Evaluation 2 (FAME-2) trial, all patients had functionally important coronary obstruction. However, percutaneous coronary intervention had no effect on death or infarction.4 Finally, in the Surgical Treatment for Ischemic Heart Failure (STICH) trial, there was no interaction between ischemia by single-photon emission computed tomography or stress echocardiography and surgical revascularization, which did not affect mortality.5Although the present study reaffirms ischemia as an independent risk marker, it does not imply that patients should be revascularized only because significant ischemia is demonstrated. The oculo-ischemic reflex toward revascularization should be replaced by a patient-centered decision, which takes clinical presentation, expected benefits for outcomes, and individual preferences as the determinant factors.Luis C.L. Correia, MD, PhDMárcia M. Noya-Rabelo, MD, MScMedical School of BahiaSalvador, BrazilJosé Augusto Barreto-Filho, MD, PhDFederal University of SergipeAracaju, BrazilDisclosuresNone.References1. Shah R, Heydari B, Coelho-Filho O, Murthy VL, Abbasi S, Feng JH, Pencina M, Neilan TG, Meadows JL, Francis S, Blankstein R, Steigner M, di Carli M, Jerosch-Herold M, Kwong RY. Stress cardiac magnetic resonance imaging provides effective cardiac risk reclassification in patients with known or suspected stable coronary artery disease.Circulation. 2013; 128:605–614.LinkGoogle Scholar2. Shaw LJ, Weintraub WS, Maron DJ, Hartigan PM, Hachamovitch R, Min JK, Dada M, Mancini GB, Hayes SW, O'Rourke RA, Spertus JA, Kostuk W, Gosselin G, Chaitman BR, Knudtson M, Friedman J, Slomka P, Germano G, Bates ER, Teo KK, Boden WE, Berman DS. Baseline stress myocardial perfusion imaging results and outcomes in patients with stable ischemic heart disease randomized to optimal medical therapy with or without percutaneous coronary intervention.Am Heart J. 2012; 164:243–250.CrossrefMedlineGoogle Scholar3. 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. 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.J Nucl Cardiol. 2012; 19: 658–669.CrossrefMedlineGoogle Scholar4. De Bruyne B, Pijls NH, Kalesan B, Barbato E, Tonino PA, Piroth Z, Jagic N, Möbius-Winkler S, Mobius-Winckler S, Rioufol G, Witt N, Kala P, MacCarthy P, Engström T, Oldroyd KG, Mavromatis K, Manoharan G, Verlee P, Frobert O, Curzen N, Johnson JB, Jüni P, Fearon WF; FAME 2 Trial Investigators. Fractional flow reserve-guided PCI versus medical therapy in stable coronary disease.N Engl J Med. 2012; 367:991–1001.CrossrefMedlineGoogle Scholar5. Panza JA, Holly TA, Asch FM, She L, Pellikka PA, Velazquez EJ, Lee KL, Borges-Neto S, Farsky PS, Jones RH, Berman DS, Bonow RO. Inducible myocardial ischemia and outcomes in patients with coronary artery disease and left ventricular dysfunction.J Am Coll Cardiol. 2013; 61:1860–1870.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails April 15, 2014Vol 129, Issue 15 Advertisement Article InformationMetrics © 2014 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.113.005797PMID: 24733545 Originally publishedApril 15, 2014 PDF download Advertisement SubjectsImagingStent
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