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Diagnosis and management of ischemic cardiomyopathy

James C Fang, MD
Sary Aranki, MD
Section Editors
Bernard J Gersh, MB, ChB, DPhil, FRCP, MACC
Wilson S Colucci, MD
Deputy Editor
Brian C Downey, MD, FACC


The term ischemic cardiomyopathy has been used to describe significantly impaired left ventricular function (left ventricular ejection fraction ≤35 to 40 percent) that results from coronary artery disease. Despite the common clinical use of the term ischemic cardiomyopathy, ventricular dysfunction caused by coronary disease is not a cardiomyopathy as defined by the 2006 American Heart Association and 2008 European Society of Cardiology statements. (See "Definition and classification of the cardiomyopathies".)

There are two main pathogenetic mechanisms, which are importantly distinguished by the possibility of corrective therapy:

Irreversible loss of myocardium due to prior myocardial infarction with ventricular remodeling. Recovery of myocardial function in such patients cannot be achieved by coronary revascularization since the infarcted tissue is not viable.

At least partially reversible loss of contractility due to reduced function of ischemic but still viable myocardium, which can be detected on imaging studies. Hibernating myocardium is typically used interchangeably with viable myocardium. However, by strict definition, the term hibernating myocardium refers to contractile dysfunction in viable myocardium that improves after revascularization or perhaps medical therapy [1]. Stunned myocardium refers to transient postischemic dysfunction and can coexist with hibernating myocardium [2]. (See "Clinical syndromes of stunned or hibernating myocardium".)

This topic will emphasize the definition, incidence, and therapy of reversible ischemic cardiomyopathy. Diagnostic issues related to hibernating viable myocardium are discussed in detail separately. (See "Evaluation of hibernating myocardium" and "Dobutamine stress echocardiography in the evaluation of hibernating myocardium" and "Assessment of myocardial viability by nuclear imaging in coronary heart disease".)


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Literature review current through: Sep 2016. | This topic last updated: Apr 28, 2016.
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  1. Underwood SR, Bax JJ, vom Dahl J, et al. Imaging techniques for the assessment of myocardial hibernation. Report of a Study Group of the European Society of Cardiology. Eur Heart J 2004; 25:815.
  2. Chareonthaitawee P, Gersh BJ, Araoz PA, Gibbons RJ. Revascularization in severe left ventricular dysfunction: the role of viability testing. J Am Coll Cardiol 2005; 46:567.
  3. Felker GM, Shaw LK, O'Connor CM. A standardized definition of ischemic cardiomyopathy for use in clinical research. J Am Coll Cardiol 2002; 39:210.
  4. Repetto A, Dal Bello B, Pasotti M, et al. Coronary atherosclerosis in end-stage idiopathic dilated cardiomyopathy: an innocent bystander? Eur Heart J 2005; 26:1519.
  5. Frustaci A, Chimenti C, Maseri A. Global biventricular dysfunction in patients with asymptomatic coronary artery disease may be caused by myocarditis. Circulation 1999; 99:1295.
  6. He J, Ogden LG, Bazzano LA, et al. Risk factors for congestive heart failure in US men and women: NHANES I epidemiologic follow-up study. Arch Intern Med 2001; 161:996.
  7. Suleiman M, Khatib R, Agmon Y, et al. Early inflammation and risk of long-term development of heart failure and mortality in survivors of acute myocardial infarction predictive role of C-reactive protein. J Am Coll Cardiol 2006; 47:962.
  8. Hellermann JP, Jacobsen SJ, Redfield MM, et al. Heart failure after myocardial infarction: clinical presentation and survival. Eur J Heart Fail 2005; 7:119.
  9. Bursi F, Enriquez-Sarano M, Nkomo VT, et al. Heart failure and death after myocardial infarction in the community: the emerging role of mitral regurgitation. Circulation 2005; 111:295.
  10. Felker GM, Thompson RE, Hare JM, et al. Underlying causes and long-term survival in patients with initially unexplained cardiomyopathy. N Engl J Med 2000; 342:1077.
  11. Bart BA, Shaw LK, McCants CB Jr, et al. Clinical determinants of mortality in patients with angiographically diagnosed ischemic or nonischemic cardiomyopathy. J Am Coll Cardiol 1997; 30:1002.
  12. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013; 62:e147.
  13. Authors/Task Force members, Windecker S, Kolh P, et al. 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 2014; 35:2541.
  14. Allman KC, Shaw LJ, Hachamovitch R, Udelson JE. Myocardial viability testing and impact of revascularization on prognosis in patients with coronary artery disease and left ventricular dysfunction: a meta-analysis. J Am Coll Cardiol 2002; 39:1151.
  15. Bonow RO. The hibernating myocardium: implications for management of congestive heart failure. Am J Cardiol 1995; 75:17A.
  16. Ragosta M, Beller GA, Watson DD, et al. Quantitative planar rest-redistribution 201Tl imaging in detection of myocardial viability and prediction of improvement in left ventricular function after coronary bypass surgery in patients with severely depressed left ventricular function. Circulation 1993; 87:1630.
  17. Auerbach MA, Schöder H, Hoh C, et al. Prevalence of myocardial viability as detected by positron emission tomography in patients with ischemic cardiomyopathy. Circulation 1999; 99:2921.
  18. Velazquez EJ, Lee KL, Jones RH, et al. Coronary-Artery Bypass Surgery in Patients with Ischemic Cardiomyopathy. N Engl J Med 2016; 374:1511.
  19. Hillis LD, Smith PK, Anderson JL, et al. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011; 124:2610.
  20. McMurray JJ, Adamopoulos S, Anker SD, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur Heart J 2012; 33:1787.
  21. Brundage BH, Massie BM, Botvinick EH. Improved regional ventricular function after successful surgical revascularization. J Am Coll Cardiol 1984; 3:902.
  22. Tillisch J, Brunken R, Marshall R, et al. Reversibility of cardiac wall-motion abnormalities predicted by positron tomography. N Engl J Med 1986; 314:884.
  23. Lee KS, Marwick TH, Cook SA, et al. Prognosis of patients with left ventricular dysfunction, with and without viable myocardium after myocardial infarction. Relative efficacy of medical therapy and revascularization. Circulation 1994; 90:2687.
  24. Elefteriades JA, Tolis G Jr, Levi E, et al. Coronary artery bypass grafting in severe left ventricular dysfunction: excellent survival with improved ejection fraction and functional state. J Am Coll Cardiol 1993; 22:1411.
  25. Pagley PR, Beller GA, Watson DD, et al. Improved outcome after coronary bypass surgery in patients with ischemic cardiomyopathy and residual myocardial viability. Circulation 1997; 96:793.
  26. Baer FM, Theissen P, Schneider CA, et al. Dobutamine magnetic resonance imaging predicts contractile recovery of chronically dysfunctional myocardium after successful revascularization. J Am Coll Cardiol 1998; 31:1040.
  27. Wellnhofer E, Olariu A, Klein C, et al. Magnetic resonance low-dose dobutamine test is superior to SCAR quantification for the prediction of functional recovery. Circulation 2004; 109:2172.
  28. Bax JJ, Poldermans D, Elhendy A, et al. Improvement of left ventricular ejection fraction, heart failure symptoms and prognosis after revascularization in patients with chronic coronary artery disease and viable myocardium detected by dobutamine stress echocardiography. J Am Coll Cardiol 1999; 34:163.
  29. Eitzman D, al-Aouar Z, Kanter HL, et al. Clinical outcome of patients with advanced coronary artery disease after viability studies with positron emission tomography. J Am Coll Cardiol 1992; 20:559.
  30. Samady H, Elefteriades JA, Abbott BG, et al. Failure to improve left ventricular function after coronary revascularization for ischemic cardiomyopathy is not associated with worse outcome. Circulation 1999; 100:1298.
  31. Gerber BL, Rousseau MF, Ahn SA, et al. Prognostic value of myocardial viability by delayed-enhanced magnetic resonance in patients with coronary artery disease and low ejection fraction: impact of revascularization therapy. J Am Coll Cardiol 2012; 59:825.
  32. Desideri A, Cortigiani L, Christen AI, et al. The extent of perfusion-F18-fluorodeoxyglucose positron emission tomography mismatch determines mortality in medically treated patients with chronic ischemic left ventricular dysfunction. J Am Coll Cardiol 2005; 46:1264.
  33. Velazquez EJ, Lee KL, Deja MA, et al. Coronary-artery bypass surgery in patients with left ventricular dysfunction. N Engl J Med 2011; 364:1607.
  34. Mark DB, Knight JD, Velazquez EJ, et al. Quality-of-life outcomes with coronary artery bypass graft surgery in ischemic left ventricular dysfunction: a randomized trial. Ann Intern Med 2014; 161:392.
  35. Bonow RO, Maurer G, Lee KL, et al. Myocardial viability and survival in ischemic left ventricular dysfunction. N Engl J Med 2011; 364:1617.
  36. Bax JJ, van der Wall EE, Harbinson M. Radionuclide techniques for the assessment of myocardial viability and hibernation. Heart 2004; 90 Suppl 5:v26.
  37. Carluccio E, Biagioli P, Alunni G, et al. Patients with hibernating myocardium show altered left ventricular volumes and shape, which revert after revascularization: evidence that dyssynergy might directly induce cardiac remodeling. J Am Coll Cardiol 2006; 47:969.
  38. Rahimtoola SH, La Canna G, Ferrari R. Hibernating myocardium: another piece of the puzzle falls into place. J Am Coll Cardiol 2006; 47:978.
  39. Shah DJ, Kim HW, James O, et al. Prevalence of regional myocardial thinning and relationship with myocardial scarring in patients with coronary artery disease. JAMA 2013; 309:909.
  40. Jones RH, Velazquez EJ, Michler RE, et al. Coronary bypass surgery with or without surgical ventricular reconstruction. N Engl J Med 2009; 360:1705.
  41. Schinkel AF, Poldermans D, Rizzello V, et al. Why do patients with ischemic cardiomyopathy and a substantial amount of viable myocardium not always recover in function after revascularization? J Thorac Cardiovasc Surg 2004; 127:385.
  42. Cleland JG, Pennell DJ, Ray SG, et al. Myocardial viability as a determinant of the ejection fraction response to carvedilol in patients with heart failure (CHRISTMAS trial): randomised controlled trial. Lancet 2003; 362:14.
  43. Holper EM, Blair J, Selzer F, et al. The impact of ejection fraction on outcomes after percutaneous coronary intervention in patients with congestive heart failure: an analysis of the National Heart, Lung, and Blood Institute Percutaneous Transluminal Coronary Angioplasty Registry and Dynamic Registry. Am Heart J 2006; 151:69.
  44. Sedlis SP, Ramanathan KB, Morrison DA, et al. Outcome of percutaneous coronary intervention versus coronary bypass grafting for patients with low left ventricular ejection fractions, unstable angina pectoris, and risk factors for adverse outcomes with bypass (the AWESOME Randomized Trial and Registry). Am J Cardiol 2004; 94:118.
  45. Luu M, Stevenson LW, Brunken RC, et al. Delayed recovery of revascularized myocardium after referral for cardiac transplantation. Am Heart J 1990; 119:668.
  46. Louie HW, Laks H, Milgalter E, et al. Ischemic cardiomyopathy. Criteria for coronary revascularization and cardiac transplantation. Circulation 1991; 84:III290.
  47. Bortman G, Sellanes M, Odell DS, et al. Discrepancy between pre- and post-transplant diagnosis of end-stage dilated cardiomyopathy. Am J Cardiol 1994; 74:921.
  48. Mickleborough LL, Maruyama H, Takagi Y, et al. Results of revascularization in patients with severe left ventricular dysfunction. Circulation 1995; 92:II73.
  49. Kron IL, Flanagan TL, Blackbourne LH, et al. Coronary revascularization rather than cardiac transplantation for chronic ischemic cardiomyopathy. Ann Surg 1989; 210:348.