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Diagnosis and management of ischemic cardiomyopathy

INTRODUCTION

The term ischemic cardiomyopathy is currently applied to patients with significantly impaired left ventricular dysfunction (left ventricular ejection fraction ≤35 to 40 percent) that results from coronary artery disease. 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 (MI) 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 myocardium will be briefly reviewed and are discussed in detail separately. (See "Evaluation of hibernating myocardium".)

DEFINITION

An effort to provide a standardized definition of ischemic cardiomyopathy was made in a review of 1921 patients with symptomatic HF and an LVEF <40 percent who underwent coronary angiography [3]. Ischemic cardiomyopathy was considered to be present in patients with HF who have had an MI or have evidence of hibernating myocardium or, on angiography, severe coronary disease. Such patients had a worse outcome than those with nonischemic cardiomyopathy. In contrast, patients with single vessel disease who had no history of myocardial infarction or revascularization had a similar prognosis as those with nonischemic cardiomyopathy. It was suggested that such patients should be classified as nonischemic cardiomyopathy, at least for prognostic purposes [3].

However, without evidence of prior infarction or hibernating myocardium, the presence of asymptomatic angiographic coronary artery disease in patients with dilated cardiomyopathy does not prove causality. The development of severe coronary disease as a secondary event was demonstrated in a study of 55 patients who underwent heart transplantation with a pretransplant diagnosis of idiopathic dilated cardiomyopathy [4]. All of the patients had had a normal coronary arteriogram within the preceding 10 years and none had a history of ischemic events. Examination of the explanted heart revealed critical lesions in at least one coronary artery segment in 15 patients (27 percent) with no evidence of scars.
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