OBJECTIVE ASSESSMENT OF CARDIOPROTECTIVE EFFICACY AS A PROGNOSTIC GUIDE TO MANAGEMENT OF MILDLY SYMPTOMATIC REVASCULARIZABLE CORONARY-ARTERY DISEASE

Objectives. The concept of ''cardioprotection'' based on ejection frac tion was tested to see whether patients with coronary artery disease i n whom medical treatment fails to be cardioprotective can be distingui shed from those in whom it is safe to continue such treatment. Backgro und. Ejection fraction is of fundamental prognostic importance, Its mo dification by anti-ischemic medication may allow assessment of cardiop rotection from adverse outcome. Methods. Exercise ejection fraction an d the change in ejection fraction from rest to exercise were measured by radionuclide ventriculography with and without background medicatio n in 102 mildly symptomatic patients with coronary artery disease suit able for revascularization but initially treated medically. Results. O ver 20 months, 23 patients experienced an adverse event, With medicati on, exercise ejection fraction increased in patients with and without events, By contrast, the ejection fraction response to exercise improv ed significantly in the event-free group only; the group with events h ad a persistent decrease in ejection fraction, By Cox analysis, the ej ection fraction response to exercise performed with medication made th e most significant independent contribution to event-free survival, Co mparison of areas under receiver operating characteristic curves sugge sted that this index is the most useful clinical measure of cardioprot ection. Conclusions. An exercise induced decrease in ejection fraction despite anti-ischemic medication implies failure of cardioprotection and a greater short-term risk of adverse outcome and crossover to reva scularization in patients initially treated medically, Conversely, a p reserved left ventricular performance confers a satisfactory prognosis while continuing with that treatment, Thus, the effect of medication on the ejection fraction response to exercise-a reasonable estimate of its cardioprotective efficacy-may influence the choice of continuing with such treatment or performing early revascularization.