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Author Spotlight: Enhancing Coronary Artery Revascularization
Published on: September 15, 2023
Coronary-Artery Bypass Surgery in Patients with Ischemic Cardiomyopathy
Eric J Velazquez1, Kerry L Lee1, Robert H Jones1
1From the Division of Cardiology (E.J.V.), Departments of Biostatistics and Bioinformatics (K.L.L., H.R.A.-K.) and Surgery (R.H.J.), and Duke Clinical Research Institute (L.S., V.L.M.), Duke University Medical Center, Durham, NC; the University of Florida, Gainesville (J.A.H.); Westchester Medical Center and New York Medical College, Valhalla (J.A.P.), and Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York (R.E.M.); Northwestern University Feinberg School of Medicine, Chicago (R.O.B.); the Department of Cardiothoracic Surgery, University Hospital Jena, Friedrich-Schiller-University of Jena, Jena, Germany (T.D.); Glasgow University and Golden Jubilee National Hospital, Glasgow, United Kingdom (M.C.P.); Mayo Clinic, Rochester, MN (J.K.O.); the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.D.-N., G.S.); and University of Montreal, Montreal Heart Institute, Montreal (J.L.R.).
Insights
Coronary-artery bypass grafting (CABG) significantly reduces long-term mortality and hospitalizations in patients with ischemic cardiomyopathy. Adding CABG to medical therapy improves survival outcomes compared to medical therapy alone.
Area of Science:
- Cardiology
- Cardiac Surgery
- Clinical Trials
Background:
- Uncertainty exists regarding the survival benefit of coronary-artery bypass grafting (CABG) plus guideline-directed medical therapy versus medical therapy alone in patients with coronary artery disease, heart failure, and severe left ventricular systolic dysfunction.
- Ischemic cardiomyopathy presents a significant clinical challenge, necessitating evaluation of optimal treatment strategies.
Purpose of the Study:
- To determine the long-term survival benefit of adding coronary-artery bypass grafting (CABG) to guideline-directed medical therapy in patients with ischemic cardiomyopathy.
- To compare the composite outcomes of death from any cause or hospitalization for cardiovascular causes between the CABG plus medical therapy group and the medical therapy alone group.
Main Methods:
- A randomized controlled trial involving 1212 patients with ejection fraction ≤35% and coronary artery disease amenable to CABG.
- Patients were assigned to either CABG plus medical therapy (610 patients) or medical therapy alone (602 patients).
- The primary outcome was all-cause mortality, with secondary outcomes including cardiovascular death and composite outcomes over a median follow-up of 9.8 years.
Main Results:
- Coronary-artery bypass grafting (CABG) significantly reduced the risk of death from any cause (hazard ratio, 0.84; P=0.02).
- CABG also significantly decreased cardiovascular mortality (hazard ratio, 0.79; P=0.006) and the composite of death from any cause or hospitalization for cardiovascular causes (hazard ratio, 0.72; P<0.001).
- These benefits were sustained over a long-term follow-up period.
Conclusions:
- In patients with ischemic cardiomyopathy, coronary-artery bypass grafting (CABG) combined with medical therapy leads to significantly lower rates of all-cause mortality, cardiovascular mortality, and hospitalizations over 10 years compared to medical therapy alone.
- The findings support the use of CABG in selected patients with severe left ventricular systolic dysfunction and coronary artery disease.
- The STICHES trial provides robust evidence for the long-term efficacy of surgical intervention in this patient population.
Background:
The survival benefit of a strategy of coronary-artery bypass grafting (CABG) added to guideline-directed medical therapy, as compared with medical therapy alone, in patients with coronary artery disease, heart failure, and severe left ventricular systolic dysfunction remains unclear.
Methods:
From July 2002 to 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 undergo CABG plus medical therapy (CABG group, 610 patients) or medical therapy alone (medical-therapy group, 602 patients). The primary outcome was death from any cause. Major secondary outcomes included death from cardiovascular causes and death from any cause or hospitalization for cardiovascular causes. The median duration of follow-up, including the current extended-follow-up study, was 9.8 years.
Results:
A primary outcome event occurred in 359 patients (58.9%) in the CABG group and in 398 patients (66.1%) in the medical-therapy group (hazard ratio with CABG vs. medical therapy, 0.84; 95% confidence interval [CI], 0.73 to 0.97; P=0.02 by log-rank test). A total of 247 patients (40.5%) in the CABG group and 297 patients (49.3%) in the medical-therapy group died from cardiovascular causes (hazard ratio, 0.79; 95% CI, 0.66 to 0.93; P=0.006 by log-rank test). Death from any cause or hospitalization for cardiovascular causes occurred in 467 patients (76.6%) in the CABG group and in 524 patients (87.0%) in the medical-therapy group (hazard ratio, 0.72; 95% CI, 0.64 to 0.82; P<0.001 by log-rank test).
Conclusions:
In a cohort of patients with ischemic cardiomyopathy, the rates of death from any cause, death from cardiovascular causes, and death from any cause or hospitalization for cardiovascular causes were significantly lower over 10 years among patients who underwent CABG in addition to receiving medical therapy than among those who received medical therapy alone. (Funded by the National Institutes of Health; STICH [and STICHES] ClinicalTrials.gov number, NCT00023595.).
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