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Medical therapy and outcomes in REVIVED-BCIS2 and STICHES: an individual patient data analysis
Matthew Ryan1,2, Mark C Petrie3, Evangelos Kontopantelis4
1Kings College London, British Heart Foundation Centre of Research Excellence, 4th Floor Lambeth Wing, St Thomas' Hospital, Westminster Bridge Road, London SE1 7EH, UK.
Insights
Patients with ischaemic cardiomyopathy receiving medical therapy alone in the REVIVED-BCIS2 trial had better outcomes than those in the STICHES trial. Further research comparing coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), and medical therapy is needed.
Area of Science:
- Cardiology
- Cardiovascular Surgery
- Interventional Cardiology
Background:
- Coronary artery bypass grafting (CABG) improved outcomes in the STICHES trial for patients with ischaemic left ventricular dysfunction on medical therapy.
- Percutaneous coronary intervention (PCI) did not improve outcomes in the REVIVED-BCIS2 trial for similar patients.
Purpose of the Study:
- To compare outcomes of patients receiving medical therapy alone in STICHES versus REVIVED-BCIS2.
- To evaluate the incremental benefit of CABG or PCI in patients with ischaemic cardiomyopathy.
Main Methods:
- Pooled analysis of individual participant data from two multicentre randomized trials (STICHES and REVIVED-BCIS2).
- Included patients had left ventricular ejection fraction ≤35%, coronary artery disease, and received medical therapy.
- Participants were randomized to CABG (STICHES) or PCI (REVIVED-BCIS2). Primary outcome: all-cause death or heart failure hospitalization.
Main Results:
- Patients on medical therapy alone in REVIVED-BCIS2 had significantly fewer primary outcome events than those in STICHES (aHR 0.60, P < .001).
- PCI in REVIVED-BCIS2 was associated with fewer primary outcome events compared to CABG in STICHES.
- Outcomes for patients treated with CABG in STICHES were worse than for those on medical therapy alone in REVIVED-BCIS2.
Conclusions:
- Medical therapy alone in REVIVED-BCIS2 yielded better outcomes for ischaemic cardiomyopathy patients than in STICHES, irrespective of revascularization strategy.
- Further trials are warranted to compare CABG, PCI, and medical therapy in this patient population.
Background And Aims:
In the Surgical Treatment for Ischaemic Heart Failure Trial Extension Study (STICHES), coronary artery bypass grafting (CABG) improved outcomes of patients with ischaemic left ventricular dysfunction receiving medical therapy, whereas in the Revascularization for Ischaemia Ventricular Dysfunction trial (REVIVED-BCIS2), percutaneous coronary intervention (PCI) did not. The aim of this study was to explore differences in outcomes of participants treated with medical therapy alone in STICHES vs. REVIVED-BCIS2 and to assess the incremental benefit of CABG or PCI.
Methods:
Pooled analysis of adjusted individual participant data from two multicentre randomized trials. All patients had left ventricular ejection fraction ≤35% and coronary artery disease and received medical therapy. Participants were randomized 1:1 to CABG (STICHES) or PCI (REVIVED-BCIS2). The primary outcome was the composite of all-cause death and hospitalization for heart failure over all available follow-up.
Results:
A total of 1912 participants (88% male, 76% white ethnicity) were included with 98.3% completeness of follow-up for the primary outcome. The median follow-up was 118 months in STICHES and 41 months in REVIVED-BCIS2. Those receiving medical therapy alone in REVIVED-BCIS2 had fewer primary outcome events than those receiving medical therapy alone in STICHES (adjusted hazard ratio 0.60, 95% confidence interval 0.48-0.74, P < .001). Patients receiving PCI in REVIVED-BCIS2 were less likely to experience a primary outcome event than those receiving CABG in STICHES. Adjusted outcomes of patients treated with CABG in STICHES were worse than those receiving medical therapy alone in REVIVED-BCIS2.
Conclusions:
Patients with ischaemic cardiomyopathy receiving medical therapy in REVIVED-BCIS2 had better outcomes than those in STICHES, with or without CABG surgery. Further trials comparing CABG, PCI, and medical therapy in this population are warranted.
