Best of heart failure

27 Introduction Heart failure (HF) is a growing public health issue world- wide as the incidence and prevalence of HF continue to steadily increase over the last decades. This trend is in part due to improved survival of patients with cardiovascular diseases and an aging general population [ 1 ]. Coronary artery disease (CAD) represents the predominant etiology of HF and left ventricular (LV) dysfunction [ 2 ]. In fact, almost 60% of the patients enrolled in the Acute Decom- pensated Heart Failure National Registry had a history significant for CAD [ 3 ]. Moreover, ongoing ischemia is a common precipitant of acute decompensated HF [ 4 ]. While guideline-directed medical therapy remains the cornerstone treatment strategy for these patients, coro- nary revascularization is sometimes indicated in HF pa- tients with CAD [ 5 ]. Although revascularization by coro- nary artery bypass grafting (CABG) and/or percutaneous coronary interventions (PCI) has been studied in differ- ent settings, there is relatively little evidence for such strategies in patients with HF and CAD, particularly in cases with advanced HF and cardiogenic shock (CS). Lastly, the use of acute mechanical circulatory devices (AMCS), durable mechanical circulatory devices, and bridge strategies must be considered in these patients undergoing revascularization by a multidisciplinary team. Here, we review the current treatment options and available data for revascularization in patients with ischemic cardiomyopathy (ICM), advanced HF, and CS. The Heart Failure Association (HFA), American Col- lege of Cardiology/American Heart Association, and Heart Failure Society of America have used various criteria to define advanced HF [ 6 , 7 ]. Furthermore, the Interagency Registry for Mechanically Assisted Circula- tory Support (INTERMACS) has designated different clinical profiles dictating the need for advanced thera- pies [ 8 • ]. In 2018, the HFA of the European Society of Cardiology published a position statement with an up- dated definition of advanced HF (Table 1 ) to include patients with clinical features of HF with preserved ejec- tion fraction and with unplanned outpatient visits for HF [ 10 , 11 ]. An understanding of the severity, complex- ity, and diversity of the HF syndrome is needed for patients planned to undergo revascularization. Revascularization strategies in heart failure with reduced ejection fraction secondary to coronary artery disease: CABG versus PCI Left ventricular dysfunction and CAD frequently coexist with comorbidities that translate into higher risk for invasive or surgical procedures. Although new technologies and tools have been designed and introduced, revascularization strategies in the setting of LV dysfunction remain an area of interest and debate. The Surgical Treatment for Ischemic Heart Failure (STICH) trial compared optimal medical therapy (OMT) plus CABG with OMT in 1212 patients with ICM and LV ejection fraction of ≤ 35% [ 12 •• ]. Mortality within the first 30 days was significantly higher in the surgical group (4% vs. 1%; HR 3.12; 95% CI 1.33 to 7.32; p = 0.009). At a median of 4.6 years, OMT plus CABG did not result in a significant reduction in the primary outcome of all-cause mortality compared with those assigned to OMT alone (36% vs. 41%; HR 0.86; 95%CI 0.72 to 1.04; p = 0.12). More recently, however, the STICH Extension Study did find a sig- nificant extended effect of CABG on top of OMT in this cohort of patients. Here, after a median follow-up of 9.8 years, all-cause mortality was significantly reduced in the CABG group compared to that in OMT alone (59% vs. 66%; HR 0.84; 95% CI 0.73 – 0.97; p = 0.02) (Fig. 1 ). Moreover, the CABG group had significant reductions in the prespecified secondary outcomes of cardiovascular 4 Page 2 of 12 Curr Treat Options Cardio Med (2019) 21: 4