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Author Spotlight: Enhancing Coronary Artery Revascularization
Published on: September 15, 2023
Extent of coronary and myocardial disease and benefit from surgical revascularization in ischemic LV dysfunction
Julio A Panza1, Eric J Velazquez2, Lilin She3
1Westchester Medical Center and New York Medical College, Valhalla, New York.
Insights
Coronary artery bypass graft surgery (CABG) significantly benefits patients with advanced ischemic cardiomyopathy, particularly those with multiple adverse prognostic factors. Early risks of CABG are surpassed by long-term survival advantages in these individuals.
Area of Science:
- Cardiology
- Cardiac Surgery
- Clinical Trials
Background:
- Patients with ischemic left ventricular dysfunction face elevated risks with coronary artery bypass graft surgery (CABG).
- Identifying patients who experience survival benefits outweighing initial risks after CABG is crucial.
Purpose of the Study:
- To investigate how anatomical factors associated with poor prognosis influence the effectiveness of CABG in ischemic cardiomyopathy.
- To determine if specific patient subgroups benefit more from CABG.
Main Methods:
- Analysis of 1,212 patients from the STICH trial with coronary artery disease (CAD) and ejection fraction (EF) ≤35%.
- Patients were randomized to CABG plus optimal medical therapy (OMT) or OMT alone.
- Focus on three prognostic factors: 3-vessel CAD, EF <27%, and end-systolic volume index (ESVI) >79 ml/m(2).
Main Results:
- CABG reduced mortality in patients with 2-3 prognostic factors (HR: 0.71; p=0.004), but not in those with 0-1 factor (HR: 1.08; p=0.591).
- A significant interaction (p=0.022) was observed between the number of factors and CABG's effect on mortality.
- Long-term ( >2 years) net survival benefit of CABG was seen in patients with 2-3 factors (HR: 0.53; p<0.001), despite higher 30-day risk.
Conclusions:
- Patients with more severe ischemic cardiomyopathy, indicated by extensive CAD and worse myocardial dysfunction, derive greater benefit from CABG.
- This finding supports the use of surgical revascularization for patients with advanced disease.
- The STICH trial provides evidence for CABG indications in specific patient populations.
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).
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