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J Am Coll Cardiol. 2014 Aug 12;64(6):553-61. doi: 10.1016/j.jacc.2014.04.064.

Extent of coronary and myocardial disease and benefit from surgical revascularization in ischemic LV dysfunction [Corrected].

Author information

1
Westchester Medical Center and New York Medical College, Valhalla, New York. Electronic address: PanzaJ@wcmc.com.
2
Duke Clinical Research Institute, Department of Medicine-Cardiology, Duke University School of Medicine, Durham, North Carolina.
3
Duke Clinical Research Institute, Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC.
4
Duke Clinical Research Institute, Department of Surgery-Cardiothoracic, Duke University School of Medicine, Durham, North Carolina.
5
InCor Heart Institute, University of São Paulo Medical School, São Paulo, Brazil.
6
University Hospital Favaloro Foundation, Buenos Aires, Argentina.
7
Belgrade University School of Medicine, Belgrade, Serbia.
8
Department of Cardiology, Medical University of Lodz, Lodz, Poland.
9
Centre for Chronic Disease Control, New Delhi, India.
10
Foothills Medical Centre, Calgary, Canada.
11
Medical University of Silesia, Katowice, Poland.
12
Shands Hospital at the University of Florida, Gainesville, Florida.
13
Institute of Cardiology, Warsaw, Poland.
14
Royal Perth Hospital, Perth, Australia.
15
National Heart, Lung, and Blood Institute, Bethesda, Maryland.
16
Montréal Heart Institute, Université de Montréal, Montréal, Quebec, Canada.

Erratum in

  • J Am Coll Cardiol. 2014 Oct 7;64(14):1539.

Abstract

BACKGROUND:

Patients with ischemic left ventricular dysfunction have higher operative risk with coronary artery bypass graft surgery (CABG). However, those whose early risk is surpassed by subsequent survival benefit have not been identified.

OBJECTIVES:

This study sought to examine the impact of anatomic variables associated with poor prognosis on the effect of CABG in ischemic cardiomyopathy.

METHODS:

All 1,212 patients in the STICH (Surgical Treatment of IsChemic Heart failure) surgical revascularization trial were included. Patients had coronary artery disease (CAD) and ejection fraction (EF) of ≤35% and were randomized to receive CABG plus medical therapy or optimal medical therapy (OMT) alone. This study focused on 3 prognostic factors: presence of 3-vessel CAD, EF below the median (27%), and end-systolic volume index (ESVI) above the median (79 ml/m(2)). Patients were categorized as having 0 to 1 or 2 to 3 of these factors.

RESULTS:

Patients with 2 to 3 prognostic factors (n = 636) had reduced mortality with CABG compared with those who received OMT (hazard ratio [HR]: 0.71; 95% confidence interval [CI]: 0.56 to 0.89; p = 0.004); CABG had no such effect in patients with 0 to 1 factor (HR: 1.08; 95% CI: 0.81 to 1.44; p = 0.591). There was a significant interaction between the number of factors and the effect of CABG on mortality (p = 0.022). Although 30-day risk with CABG was higher, a net beneficial effect of CABG relative to OMT was observed at >2 years in patients with 2 to 3 factors (HR: 0.53; 95% CI: 0.37 to 0.75; p<0.001) but not in those with 0 to 1 factor (HR: 0.88; 95% CI: 0.59 to 1.31; p = 0.535).

CONCLUSIONS:

Patients with more advanced ischemic cardiomyopathy receive greater benefit from CABG. This supports the indication for surgical revascularization in patients with more extensive CAD and worse myocardial dysfunction and remodeling. (Comparison of Surgical and Medical Treatment for Congestive Heart Failure and Coronary Artery Disease [STICH]; NCT00023595).

KEYWORDS:

coronary artery disease; heart failure; left ventricular dysfunction; myocardial ischemia; outcomes

Comment in

PMID:
25104523
PMCID:
PMC4129547
DOI:
10.1016/j.jacc.2014.04.064
[Indexed for MEDLINE]
Free PMC Article

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