Thread by @dr_benoy_n_shah

#ESCCongress
A bit of a deep dive on #REVIVED - not ocean floor deep, but just a little more than below the surface!

A lot has already been discussed today, so I'll try not to be too repetitive

#ESCCongress
This was NOT a trial of revasc in highly symptomatic patients or ACS patients. It was designed to answer the Q of whether PCI is beneficial in ischaemic myocardial dysfunction / ischaemic cardiomyopathy

#ESCCongress
These multi-centre RCTs are very hard work for steering committees and PIs, huge congrats to everyone that worked on delivering this trial - well done!

#ESCCongress
MAIN incl criteria:
LV EF <35%
Extensive CAD (defined by BCIS Jeopardy score)
Viability in at least 4 LV segments subtended by a diseased artery

MAIN excl criteria:
ACS within past 6 weeks
Severe angina
eGFR <25

Note, LMS disease not an exclusion criterion

#ESCCongress
Viability could be assessed by DSE, CMR or SPECT, depending on local availability & expertise

70% had CMR, 26% DSE & 4% nuclear

For CMR, viability defined as <25% TEI of LGE, or if 26-50% at local centre's discretion depending on if low-dose DOB then given

#ESCCongress
It took *40 centres* 7 years to recruit 700 patients across the UK

Mean age 70yrs
88% male
90% Caucasian
50% prior MI
~18% AF
70% NYHA I - II
2/3 had no angina, remaining 1/3 minimal or non-limiting angina
Mean LV EF 27%

Median follow-up 41 months (3.4 years)

#ESCCongress
We are misisng full data regarding the viability testing but also regarding revasc

We know that median number of treated vesssels was 2, that 97% stents were DES, that LMS disease present in 14% & proximal LAD disease in just over 50%
3VD in ~40% and 2VD in ~50%

#ESCCongress
We don't know what % stent deployments were guided by IVUS or OCT (or both), what % had FFR/iFR measured (will come back to that) & how coronary anatomy talied with viability tests

That data is all to come, apparently...

#ESCCongress
Unplanned revasc was 2.9% in PCI group vs 10.5% in GDMT only group - exact details for why unplanned revasc performed not clear but, looking at this table, it could well have been for the spontaneous MIs?

#ESCCongress
Primary EP - all-cause death or HF hospitalization - occurred in 40%

Death occurred in just under 1/3 patients

We should stop & read that again - with best GDMT in 2022, nearly 1 in 3 people with ischaemic CM were dead within 3.4yrs follow-up 😞

#ESCCongress
I won't delve into all the 2ndry EPs, it's all there in the paper. And we've discussed unplanned revasc, the one with the most eye-catching KM curve

The study conclusion - that event rates in this population are high, and this is not improved by adding PCI to GDMT

#ESCCongress
So, thoughts...

1) I know it is so tempting to compare this trial to STICH but, please, stop it! STICH was so different:

1) CABG, not PCI
2) Yonks ago, pre-ARNI & pre-SGLT2i
3) Viability testing not mandated
4) No CMR in viability sub-study

etc etc

#ESCCongress
I have seen that some are critising the authors for 'only' doing viability testing and not mandating ischaemia testing too

Well...that's not straight forward & I don't believe the data support that requirement either

We touched on this issue in our review back in 2013. The data on this are conflicting

Recall the original 'Smart Heart' hypothesis by the late great Shahbuddin Rahimtoola - that the heart tries to protect itself from ischaemia by downregulation & limiting cellular activities...

#ESCCongress
So, should we really be surprised that we cannot induce ischaemia, in myocardium that (we believe) is trying to protect itself from ischaemic insults?

Also, if myocardium is dysfunctional at rest but not scar tissue / infarcted, *by definition* it is ischaemic

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This leads on to 'physiologic assessment' of lesion severity - should we expect FFR / iFR measurements in these patients in this setting?

I'm not an IC, but I don't see the role of those measurements here (in severe LVSD)

IMPORTANT CAVEATS

1) This does not apply to ACS patients
2) This does not apply to highly symptomatic patients
3) The results in the GDMT group may be less impressive in healthcare systems where ARNI / SGLT2i / MRA are less widely accessible
4) We don't know full revasc details

#ESCCongress
TAKE HOME MESSAGES

1) 'Routine' PCI in patients with ischaemic CM does not improve prognosis at short/mid term follow-up. 10yr follow-up will be good to see
2) Modern GDMT +/- ICD +/- CRT is good but morbidity & mortality are still v high

3) This trial has major implications not just for the HF & IC docs but also the imaging community

What *exactly* is the role of viability testing going forwards?

Here is a table comparing prior studies looking at hibernating myocardium...

#ESCCongress
We still often get requests from surgeons for low-dose DSE to prove presence of contractile reserve in patients with poor LV function, pre-CABG or pre-valve surgery

Such long-standing ingrained practices take time to change. I don't think they will change overnight

#ESCCongress
But we should think carefully whether these tests are needed and, if so, when?

STICHES showed CABG benefit at 10 years compared to GDMT alone, and that was in a trial that did not select patients based on viability (though most did have viability)

So, lots to think about, I think the result is as expected

Modern GDMT is good, but I would't get too excited with 40% having events and ~1/3 dead after just 3.4 years...that is not great

ANSWER - Prevention!!
Much better to stop people getting ischaemic CM in the 1st place!

Finally, don't miss the excellent write-up of this trial by @michaelTCTMD for @TCTMD here:

tctmd.com/news/pci-no-be…

@ShelleyWood2 @ShelleyZieroth @DrJayMohan

Also, you can watch @mmamas1973 discussing the trial with Dr Perera here:

tctmd.com/videos/the-rev…