Summary
Background
Limited recent data are available in the literature on whether the presence of left ventricular systolic dysfunction (LVSD) affects the therapeutic management of patients with stable coronary artery disease (CAD).
Aims
The objectives of this study were to analyse prevalence, effect on therapeutics and prognosis of LVSD in stable CAD.
Methods
We prospectively included 4184 CAD outpatients free from any myocardial infarction or coronary revascularization for > 1 year. Left ventricular ejection fraction (EF) was available for 4124 (98.6%) patients. Follow-up was performed at 2 years. All events were adjudicated blindly.
Results
The mean EF was 57.5 ± 10.8%, and 201 (4.9%) patients had an EF ≤ 35%. The prescription of renin–angiotensin system inhibitors and beta-blockers was inversely related to EF, and reached > 90% in patients with EF ≤ 35%. Seventy-five (37.3%) of the patients with EF ≤ 35% received a mineralocorticoid receptor antagonist. Eighty-five (42.3%) of the patients with EF ≤ 35% had an implantable cardioverter defibrillator. Clinical follow-up data were obtained for 4090 patients (99.2%). Event rates were higher in patients with low EF (adjusted hazard ratio [95% confidence interval] for EF ≤ 35%, with EF ≥ 60% as reference: 3.93 [2.60–5.93] and 7.12 [3.85–13.18], for all-cause death and cardiovascular death, respectively).
Conclusions
In patients with stable CAD, LVSD is well taken into account by cardiologists, with extensive use of evidence-based medications and interventions. Despite this, LVSD remains a major prognostic indicator in this population.
Résumé
Contexte
Il n’existe que peu de données concernant l’impact de la dysfonction systolique ventriculaire gauche (DSVG) sur la prise en charge des patients présentant une maladie coronaire stable.
Objectif
Analyser la prévalence, l’impact sur les thérapeutiques, et le pronostic de la DSVG en cas de maladie coronaire stable.
Méthodes
Nous avons inclus 4184 patients coronariens ambulatoires, sans antécédent d’infarctus du myocarde ou de revacularisation coronaire < 1 an. Une mesure de fraction d’éjection ventriculaire gauche (FEVG) était disponible pour 4124 (98,6 %) patients. Le suivi clinique a été réalisé après 2 ans. Tous les événements ont été adjudiqués en insu.
Résultats
La FEVG moyenne était de 57,5 ± 10,8 % et 201 (4,9 %) des patients avaient une FEVG ≤ 35 %. La prescription d’antagonistes du système rénine–angiotensine et de bêta-bloquants variait en sens inverse de la FEVG et atteignait > 90 % en cas de FEVG ≤ 35 %. Au total, 37,5 % des patients avec FEVG ≤ 35 % recevaient une anti-aldostérone ; 42,3 % des patients avec FEVG ≤ 35 % avaient un défibrillateur automatique implantable. Un suivi clinique a été réalisé pour 4090 patients (99,2 %). Les événements étaient plus fréquents en cas de FEVG basse (HR ajustés [IC 95 %] pour une FEVG ≤ 35 % [FEVG > 60 % en référence] : 3,93 [2,60–5,93] et 7,12 [3,85–13,18], pour la mortalité totale et la mortalité cardiovasculaire, respectivement).
Conclusion
En cas de maladie coronaire stable, la DSVG est bien prise en compte par les cardiologues avec une large utilisation des thérapeutiques et interventions recommandées. En dépit de ce niveau de prise en charge, la DSVG demeure un facteur pronostique majeur dans cette population.
Background
Left ventricular function is a key determinant of outcome in patients with coronary artery disease (CAD), and therefore the subgroup with left ventricular systolic dysfunction (LVSD) deserves specific therapeutic management . According to recent guidelines , there are general secondary prevention measures that apply to all CAD patients, and additional recommendations when the ejection fraction (EF) is < 35–40%. However, practice patterns for CAD patients vary considerably , and limited recent real-life data are available in the literature on whether the presence of LVSD truly affects therapeutic management in patients with stable CAD. We addressed this question in a population of CAD patients at a distance from any coronary event (i.e. at least 1 year after any myocardial infarction [MI] or revascularization procedure). We also analysed the prognostic implications of LVSD in the modern era of stable CAD management.
Methods
Study population
CORONOR ( suivi d’une cohorte de patients COROnariens stables en région NORd-pas-de-Calais ) is a prospective multicentre registry that included 4184 consecutive outpatients with stable CAD between February 2010 and April 2011 . The patients were included by 50 cardiologists from the Nord-Pas-de-Calais region in France. Patients were considered eligible if they had evidence of CAD, defined as at least one of the following criteria: previous MI (> 1 year ago); previous coronary revascularization (> 1 year ago); and/or obstruction of ≥ 50% of the luminal diameter of at least one native coronary vessel on coronary angiography. The sole exclusion criterion was hospitalization for MI or coronary revascularization within the previous year.
This study was approved by the French medical data protection committee (CCTIRS) and was authorized by the Commission nationale de l’informatique et des libertés (CNIL) for the treatment of personal health data. All patients consented to the study after being informed via a written document of the objectives of the study and the treatment of data, as well as their rights to object, of access and of rectification.
Study design and follow-up
A case record form, which contained information regarding demographic and clinical details of the patients, including the usual cardiovascular risk factors and treatments, was completed prospectively at the initial visit by the investigators (i.e. the cardiologists). During the outpatient visit, the investigators reviewed the current treatment and entered in the case record form the treatment to be prescribed afterwards. EF was not assessed prospectively at inclusion; the investigators reported in the case record form the most recent echocardiographic assessment of EF that was available for the patient. A 2-year follow-up was performed at outpatient visits or by contacting the general practitioner as well as the patient. In case of any hospitalization during the follow-up period, hospital records were reviewed for evidence of cardiovascular events. As previously described , all clinical events were adjudicated by two investigators, and by three investigators in case of disagreement, according to prespecified definitions. The cause of death was determined after a detailed review of the circumstances of death, and was classified as cardiovascular or non-cardiovascular. Deaths from unknown causes ( n = 15) were classified as cardiovascular.
Statistical analysis
Continuous variables are described as means ± standard deviations. Categorical variables are presented as absolute numbers and/or percentages. The distribution of EF was divided into four categories (≥ 60%, 59–46%, 45–36% and ≤ 35%). Categorical and continuous variables were compared using the χ 2 test and analysis of variance (ANOVA), respectively. Cumulative event rates were estimated using the Kaplan–Meier method, and were compared using the log-rank test. Cox proportional hazard analyses were performed to calculate hazard ratios (HRs) and 95% confidence intervals (CIs). For each variable, the proportional hazards assumption was tested visually using Kaplan–Meier curves, and by examining a plot of –ln [–ln (survival time)] against ln (time). In addition, the proportional hazard was assessed and satisfied by including an interaction time-dependent term in the multivariable Cox regression analysis. All statistical analyses were performed with STATA ® 9.2 software (STATA Corporation, College Station, TX, USA). Statistical significance was assumed at a P value < 0.05.
Results
The baseline characteristics of the 4184 patients included in the CORONOR study have been reported . CAD was confirmed by coronary angiography in nearly all patients (99.2%). A measurement of EF was reported by the cardiologist for 4124 patients (98.6%). The mean EF was 57.5 ± 10.8%. More than half of the patients (55.2%) had an EF ≥ 60%, 29.4% had an EF between 59% and 46%, 10.5% had an EF between 45% and 36%, while 4.9% ( n = 201) had an EF ≤ 35%.
As shown in Table 1 , there were significant differences in baseline characteristics according to EF. Patients with low EF more frequently had a history of diabetes mellitus, atrial fibrillation, stroke, MI and multivessel CAD; they also had more frequently a history of hospitalization for heart failure (HF). By contrast, age did not differ among the four groups. Although the rates of history of myocardial revascularization overall were high in all groups, history of coronary stenting was more frequent in patients with high EF, while history of coronary bypass was more frequent in patients with low EF.
| EF ≥ 60% ( n = 2275) | EF 59–46% ( n = 1213) | EF 45–36% ( n = 435) | EF ≤ 35% ( n = 201) | P | |
|---|---|---|---|---|---|
| Age (years) | 67 ± 11.4 | 66.5 ± 11.6 | 67.5 ± 12 | 67.2 ± 12.4 | 0.43 |
| Women | 25.3 | 18.9 | 16.8 | 21.9 | < 0.0001 |
| Body mass index (kg/m 2 ) | 28 ± 4.9 | 28.3 ± 4.9 | 28.8 ± 5.5 | 27.5 ± 5.5 | 0.02 |
| Systolic blood pressure (mmHg) | 133 ± 15 | 132 ± 16 | 130 ± 16 | 123 ± 17 | < 0.0001 |
| Heart rate (beats/minute) | 66 ± 11.5 | 66.6 ± 11.9 | 68.5 ± 12.4 | 70.4 ± 15.4 | 0.0012 |
| Persistent angina at inclusion | 7.2 | 7.6 | 7.1 | 6.5 | 0.94 |
| History of hypertension | 59.6 | 62.7 | 58.6 | 57.2 | 0.19 |
| Diabetes mellitus | 28.5 | 32.7 | 35.9 | 38.3 | < 0.0001 |
| Atrial fibrillation at inclusion | 4.8 | 8.3 | 10.8 | 21.4 | < 0.0001 |
| History of hospitalization for heart failure | 2.5 | 6.4 | 19.5 | 46.3 | < 0.0001 |
| History of stroke | 6.1 | 7.9 | 10.6 | 13.4 | < 0.0001 |
| History of MI | 51.9 | 72 | 80.5 | 83.6 | < 0.0001 |
| History of coronary angiography | 99.3 | 99.1 | 99.3 | 98.5 | 0.56 |
| Multivessel CAD | 54.3 | 60.2 | 66.4 | 64.1 | < 0.0001 |
| History of myocardial revascularization | 86.7 | 86.3 | 84.8 | 77.1 | 0.002 |
| History of coronary stent implantation | 71.1 | 67.4 | 67.1 | 57.7 | < 0.0001 |
| History of coronary bypass | 19.4 | 23.4 | 24.1 | 24.4 | 0.01 |
| eGFR < 30 mL/min/1.73 m 2 | 1.8 | 2.3 | 1.8 | 3.2 | 0.47 |
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
