PCI With Guideline-Directed Medical Therapy for HFpEF Patients With Ischemic Cardiomyopathy

A prospective, randomized, controlled, open-label, multicenter trial with blinded endpoint adjudication (PROBE design). A total of 654 patients with LVEF ≤40%, angiographically proven coronary artery disease (CAD) amenable to PCI, and symptomatic heart failure (NYHA Class II-IV) on stable GDMT will be assigned at a 1:1 ratio to: Experimental Group: PCI with contemporary DES plus GDMT Control Group: GDMT only Angiographically proven CAD is defined as a visually estimated diameter stenosis (DS) \<90% with a quantitative flow ratio (QFR) ≤0.80 in a major epicardial vessel (reference vessel diameter \[RVD\] ≥2.5 mm), which is deemed amenable to successful PCI with DES by an interventional cardiologist. Complete revascularization of all angiographically significant lesions (visually estimated stenosis ≥70% in vessels with RVD ≥2.5 mm) is encouraged, to be performed either during the index procedure or within a staged procedure within 30 days. Both arms receive optimized GDMT according to current guidelines. Given the nature of the intervention (PCI vs. no PCI), treating physicians and patients cannot be blinded. To minimize bias, a PROBE design is employed with a blinded independent Clinical Events Committee (CEC), blinded core laboratories, and blinded statisticians. The catheterization laboratory team is unblinded but not involved in follow-up decisions or endpoint assessments. Clinic/telephone follow-up is conducted at 30 days and 3, 6, 9, and 12 months, with annual passive follow-up to 24 months.