Impact of ischaemia and scar on the therapeutic benefit derived from myocardial revascularization vs. medical therapy among patients undergoing stress-rest myocardial perfusion scintigraphy

Eur Heart J. 2011 Apr;32(8):1012-24. doi: 10.1093/eurheartj/ehq500. Epub 2011 Jan 21.


Aims: Although pre-revascularization ischaemia testing is recommended, the interaction between the extent of ischaemia and myocardial scar with performance of revascularization on patient survival is unclear.

Methods and results: We identified 13 969 patients who underwent adenosine or exercise stress SPECT myocardial perfusion scintigraphy (MPS). The percent myocardium ischaemic (%I) and fixed (%F) were calculated using 5 point/20-segment MPS scoring. Patients lost to follow-up (2.8%) were excluded leaving 13 555 patients [35% with history (Hx) of known coronary artery disease (CAD), 65% exercise stress, 61% male, age 66 ± 12]. Follow-up was performed at 12-18 months for early revascularization and at >7 years for all-cause death (ACD) (mean follow-up 8.7 ± 3.3 years). All-cause death was modelled using Cox proportional hazards modelling adjusting for logistic-based propensity scores, MPS, revascularization, and baseline characteristics. During FU, 3893 ACD (29%, 3.3%/year) and 1226 early revascularizations (9.0%) occurred. After risk-adjustment, a three-way interaction was present between %I, early revascularization, and HxCAD, such that %I identified a survival benefit with early revascularization in patients without prior myocardial infarction (MI), whereas no such benefit was present in patients with prior MI (overall model χ(2)= 3932, P < 0.001; interaction P < 0.021). Further modelling revealed that after excluding patients with scar >10% total myocardium, %I identified a survival benefit in all patients.

Conclusion: In this large observational series with long-term follow-up, patients with significant ischaemia and without extensive scar were likely to realize a survival benefit from early revascularization. In contrast, the survival of patients with minimal ischaemia was superior with medical therapy without early revascularization.

Publication types

  • Comparative Study
  • Evaluation Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Cardiac-Gated Single-Photon Emission Computer-Assisted Tomography / methods
  • Cardiac-Gated Single-Photon Emission Computer-Assisted Tomography / mortality
  • Cardiotonic Agents / therapeutic use*
  • Cicatrix / complications*
  • Cicatrix / diagnostic imaging
  • Cicatrix / mortality
  • Exercise Test
  • Female
  • Humans
  • Kaplan-Meier Estimate
  • Male
  • Middle Aged
  • Myocardial Ischemia / diagnostic imaging
  • Myocardial Ischemia / mortality
  • Myocardial Ischemia / therapy*
  • Myocardial Revascularization / methods*
  • Myocardial Revascularization / mortality
  • Propensity Score
  • Radiopharmaceuticals
  • Technetium Tc 99m Sestamibi
  • Tomography, Emission-Computed, Single-Photon / methods
  • Treatment Outcome


  • Cardiotonic Agents
  • Radiopharmaceuticals
  • Technetium Tc 99m Sestamibi