Myocardial Imaging Should Not Exclude Patients With Ischemic Heart Failure From Coronary Revascularization

Ischemic heart failure (HF) is an emerging health crisis. Coronary artery disease (CAD) affects 16.8 million Americans.1 Decades of advances in the management of risk factors of acute coronary syndromes and chronic coronary atherosclerosis have increased survival and extended the treatment time horizon for affected patients, thus transforming CAD into a chronic condition. In an aging population, these advances have led to the paradox of an increasing population with attributable risk for CAD and ≈445 000 CAD-related deaths yearly.1 HF is the major manifestation of CAD and is growing in prevalence, with 5.7 million affected Americans in 2005 and 10 million projected by 2037.1 Enhanced survival from myocardial infarction accompanied by some degree of myocardial injury is now considered the basis for HF development in industrialized nations.2 Evaluation of temporal trends at the community level suggests that HF incidence in contrast to other cardiovascular diseases has not declined and increasingly affects older adults.3,4 The cost of HF care is already enormous and continues to grow, with hospital discharges for HF up 171% in 2006 from the previous decade, and directs cost estimates for HF in 2009 >$37 billion, with readmission rates for HF showing no signs of abatement.1,5 Therefore, ischemic HF likely represents the most dangerous intersection of common cardiac-related pathologies6,7 with substantial future societal impact in terms of patient suffering and healthcare consumption.Response by Mielniczuk and Beanlands on p 279The angiographic presence and severity of intraluminal epicardial coronary artery lesions are associated with incremental mortality in patients with suspected CAD and HF.8,9 Among patients with CAD, left ventricular morphological, hemodynamic, and functional abnormalities are well-established and powerful independent predictors of clinical outcomes. Coupled with congestive symptoms, end-organ dysfunction, and functional impairment, …