The STICH trial (Surgical Treatment for Ischemic Heart Failure): mode-of-death results
Peter Carson1, John Wertheimer2, Alan Miller3
1Washington DC VA Medical Center, Washington DC.
Insights
Coronary artery bypass grafting (CABG) added to medical therapy reduced sudden death and fatal pump failure in heart failure patients. These benefits, primarily observed after two years, highlight CABG
Area of Science:
- Cardiology
- Cardiac Surgery
- Clinical Trials
Background:
- Coronary artery bypass grafting (CABG) is common for ischemic cardiomyopathy, but prospective data on its impact on death causes are lacking.
- Understanding the specific effects of CABG on mortality patterns is crucial for treatment decisions.
Purpose of the Study:
- To evaluate the impact of adding coronary artery bypass grafting (CABG) to medical therapy on the mode of death in patients with heart failure.
- To analyze prospective data from a large clinical trial to determine the effect of CABG on specific causes of mortality.
Main Methods:
- The STICH (Surgical Treatment for Ischemic Heart Failure) trial enrolled 1,212 patients with ischemic cardiomyopathy and reduced ejection fraction.
- Deaths were adjudicated by a clinical events committee using pre-specified definitions to determine the mode of death for each patient.
Main Results:
- The addition of CABG therapy showed a trend towards reducing overall cardiovascular deaths (HR: 0.83).
- CABG significantly reduced sudden death (HR: 0.73) and fatal pump failure events (HR: 0.64), particularly after 24 months.
- While post-procedure deaths increased (HR: 3.11), deaths from myocardial infarction significantly decreased (HR: 0.07).
Conclusions:
- Adding CABG to medical therapy effectively reduced the most common causes of death in heart failure: sudden death and fatal pump failure.
- The survival benefits of CABG in this population become apparent primarily after two years of follow-up.
- CABG was associated with an increase in post-procedure deaths but a decrease in myocardial infarction deaths.
Objectives:
This study sought to assess the effect of the addition of coronary artery bypass grafting (CABG) to medical therapy on mode of death in heart failure.
Background:
Although CABG therapy is widely used in ischemic cardiomyopathy patients, there are no prospective clinical trial data on mode of death.
Methods:
The STICH (Surgical Treatment for Ischemic Heart Failure ) trial compared the strategy of CABG plus medical therapy to medical therapy alone in 1,212 ischemic cardiomyopathy patients with reduced ejection fraction. A clinical events committee adjudicated deaths using pre-specified definitions for mode of death.
Results:
In the STICH trial, there were 462 deaths over a median follow-up of 56 months. The addition of CABG therapy tended to reduce cardiovascular deaths (hazard ratio [HR]: 0.83; 95% confidence interval [CI]: 0.68 to 1.03; p = 0.09) and significantly reduced the most common modes of death: sudden death (HR: 0.73; 95% CI: 0.54 to 0.99; p = 0.041) and fatal pump failure events (HR: 0.64; 95% CI: 0.41 to 1.00; p = 0.05). Time-dependent estimates indicate that the protective effect of CABG principally occurred after 24 months in both categories. Deaths post-cardiovascular procedures were increased in CABG patients (HR: 3.11; 95% CI: 1.47 to 6.60), but fatal myocardial infarction deaths were lower (HR: 0.07; 95% CI: 0.01 to 0.57). Noncardiovascular deaths were infrequent and did not differ between groups.
Conclusions:
In the STICH trial, the addition of CABG to medical therapy reduced the most common modes of death: sudden death and fatal pump failure events. The beneficial effects were principally seen after 2 years. Post-procedure deaths were increased in patients randomized to CABG, whereas myocardial infarction deaths were decreased.
