For Ischemic Cardiomyopathy, Bypass Surgery May Be Better After All

April 3, 2016

For Ischemic Cardiomyopathy, Bypass Surgery May Be Better After All

  1. Howard C. Herrmann, MD

Ten-year survival in the STICH extension study was significantly better with surgery than with medical therapy alone.

  1. Howard C. Herrmann, MD

In the previously published STICH trial, 1212 patients (median age, 60) with coronary artery disease (CAD) that was amenable to coronary artery bypass grafting (CABG) and with left-ventricular ejection fractions (LVEFs) ≤35% were randomized to CABG plus medical therapy or medical therapy alone. No participants had ≥50% left-main coronary-artery stenosis or Canadian Cardiovascular Society class III–IV angina. During a median follow-up of 56 months, all-cause mortality (the primary outcome) was similar in the two groups, but the rate of death from cardiovascular causes was slightly lower with CABG (NEJM JW Cardiol May 2011 and N Engl J Med 2011; 364:1607). Now, an extension study (STICHES) lengthens the median follow-up to 9.8 years.

During the complete follow-up, CABG significantly outperformed medical therapy alone for all-cause mortality (59% vs. 66%), all-cause mortality or hospitalization for heart failure (66% vs. 75%), and death from cardiovascular causes (41% vs. 49%). The all-cause mortality advantage of CABG over medical therapy, which began to surface at about 3 years, was evident in multiple clinical and demographic subgroups, including a more marked benefit in patients with 3-vessel disease and those with LVEFs ≤28%. About 20% of patients initially assigned to medical therapy alone underwent CABG during follow-up; however, the all-cause mortality advantage of CABG persisted in a per-protocol analysis.

Comment

The lack of benefit for CABG in the original STICH trial somewhat surprised most cardiologists and surgeons, who had learned from the earliest landmark revascularization studies that patients with the worst LV function derive the greatest benefit from surgery. The longer-term data now support the original hypothesis that CABG may offer a survival benefit to patients with severe CAD and LV dysfunction, thereby offsetting the early operative risk. As the editorialists pointed out, shared and patient-specific decision-making will be key to applying these data in practice. Nonetheless, the sobering observation that the majority of these relatively young patients (in both groups) died within 10 years should encourage us to search for other effective therapies for ischemic cardiomyopathy.

Editor Disclosures at Time of Publication

  • Disclosures for Howard C. Herrmann, MD at time of publication Consultant / Advisory board Gerson Lehrman Group; Siemens; Leerink Swann; Wells Fargo; Massachusetts Medical Society; Edwards Lifesciences; O’Bryan, Brown, and Toner; ExpertConnect; Merck Sharp and Dohme; Guidepoint Global Speaker's bureau Society for Cardiovascular Angiography and Interventions; Pinnacle Health; Mayo Foundation; Cardiovascular Institute; ACC Foundation Equity Micro Interventional Devices, Inc. Grant / Research support Abbott Vascular; Edwards Lifesciences; Gore; Medtronic; St. Jude Medical; Siemens; Boston Scientific; Cardiokinetix; University of Laval; MitraSpan Editorial boards Catheterization and Cardiovascular Interventions; Circulation: Cardiovascular Interventions; Journal of Interventional Cardiology; Journal of Invasive Cardiology; Journal of the American College of Cardiology

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