Coronary-artery bypass surgery in patients with left ventricular dysfunction
Eric J Velazquez1, Kerry L Lee, Marek A Deja
1Division of Cardiovascular Medicine, Duke University Medical Center, Durham, NC, USA. eric.velazquez@duke.edu
Insights
Coronary-artery bypass grafting (CABG) did not significantly reduce overall mortality in patients with heart failure and coronary artery disease. However, CABG did lower cardiovascular death rates and hospitalizations for cardiovascular causes.
Area of Science:
- Cardiology
- Cardiac Surgery
- Heart Failure Management
Background:
- The established role of coronary-artery bypass grafting (CABG) in treating patients with coronary artery disease (CAD) and heart failure (HF) remains unclear.
- Optimal treatment strategies for this patient population require further investigation.
Purpose of the Study:
- To evaluate the efficacy of CABG in addition to medical therapy for patients with CAD and heart failure.
- To compare the primary outcome of all-cause mortality between medical therapy alone and CABG plus medical therapy.
Main Methods:
- A randomized trial involving 1212 patients with ejection fraction ≤35% and CAD suitable for CABG.
- Patients were assigned to either medical therapy alone (602) or medical therapy plus CABG (610).
- Primary outcome: all-cause mortality. Secondary outcomes: cardiovascular death, and all-cause death or cardiovascular hospitalization.
Main Results:
- No significant difference in the primary outcome of all-cause mortality (41% vs. 36%, P=0.12).
- CABG group showed lower rates of cardiovascular death (28% vs. 33%, P=0.05) and composite of all-cause death or cardiovascular hospitalization (58% vs. 68%, P<0.001).
- High rates of CABG utilization in both groups during follow-up (91% in CABG group, 17% in medical therapy group).
Conclusions:
- CABG in addition to medical therapy did not significantly reduce all-cause mortality in patients with CAD and heart failure.
- CABG was associated with reduced rates of cardiovascular death and cardiovascular hospitalizations.
- The findings suggest a potential benefit of CABG for specific cardiovascular outcomes, warranting careful consideration in treatment decisions.
Background:
The role of coronary-artery bypass grafting (CABG) in the treatment of patients with coronary artery disease and heart failure has not been clearly established.
Methods:
Between July 2002 and May 2007, a total of 1212 patients with an ejection fraction of 35% or less and coronary artery disease amenable to CABG were randomly assigned to medical therapy alone (602 patients) or medical therapy plus CABG (610 patients). The primary outcome was the rate of death from any cause. Major secondary outcomes included the rates of death from cardiovascular causes and of death from any cause or hospitalization for cardiovascular causes.
Results:
The primary outcome occurred in 244 patients (41%) in the medical-therapy group and 218 (36%) in the CABG group (hazard ratio with CABG, 0.86; 95% confidence interval [CI], 0.72 to 1.04; P=0.12). A total of 201 patients (33%) in the medical-therapy group and 168 (28%) in the CABG group died from an adjudicated cardiovascular cause (hazard ratio with CABG, 0.81; 95% CI, 0.66 to 1.00; P=0.05). Death from any cause or hospitalization for cardiovascular causes occurred in 411 patients (68%) in the medical-therapy group and 351 (58%) in the CABG group (hazard ratio with CABG, 0.74; 95% CI, 0.64 to 0.85; P<0.001). By the end of the follow-up period (median, 56 months), 100 patients in the medical-therapy group (17%) underwent CABG, and 555 patients in the CABG group (91%) underwent CABG.
Conclusions:
In this randomized trial, there was no significant difference between medical therapy alone and medical therapy plus CABG with respect to the primary end point of death from any cause. Patients assigned to CABG, as compared with those assigned to medical therapy alone, had lower rates of death from cardiovascular causes and of death from any cause or hospitalization for cardiovascular causes. (Funded by the National Heart, Lung, and Blood Institute and Abbott Laboratories; STICH ClinicalTrials.gov number, NCT00023595.).
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