A Solution from STICH | CardioSource WorldNews Interventions
JACC in a Flash | landmark Surgical Treatment for Ischemic Heart Failure (STICH) trial posed two fundamental questions: is surgical revascularization for ischemic HFrEF preferable to medical therapy, and does surgical reverse remodeling therapy change the natural history of ischemic HF compared to medical therapy? The primary results from STICH were disappointingthere were no differences in mortality between surgical and medical therapy for ischemic HF, and there were no real new insights into the utility of viability testing to discriminate between these approaches.
So, clinical judgment remains the default method when a physician is confronted with the patient who has ischemic HF. A new analysis of the STICH trial by Julio A. Panza, MD, and colleagues provides some insight into how certain variables (i.e., left ventricular ejection fraction [LVEF], number of vessels with stenoses, and the LV end-systolic volume index [ESVI]) should be incorporated into the decision-making process.
In their study, Dr. Panza and STICH investigators hypothesized that this analysis could lead to the identification of a group of patients whose early surgical risk is rapidly surpassed by subsequent survival benefit and in whom, therefore, the indication for coronary artery bypass graft surgery (CABG) is more clearly supported.
Of the 1,212 patients included in the STICH revascularization hypothesis trial, 734 had 3-vessel coronary artery disease (CAD), a median LVEF of 26.7%, and a median ESVI of 78.6 ml/m2. In this cohort, 576 patients had 0-1 of these of prognostic factors, and 636 patients had 2-3 prognostic factors. As expected, compared with patients with 0-1 prognostic factors, those with 2-3 factors had a greater prevalence of characteristics associated with poor prognosis.
These higher-risk patients had reduced mortality with CABG, compared with those who received optimal medical therapy (HR= 0.71; 95% CI 0.56-0.89; p = 0.004). On the other hand, CABG had no such effect in patients with 0 or 1 factor (HR = 1.08; 95% CI 0.81-1.44; p = 0.591). There was also a significant interaction between the number of factors and the effect of CABG on mortality (p = 0.022).
Notably, the authors determined, 30-day risk with CABG was higher, but the benefit of surgical revascularization in the longer-term (>2 years) was greater when the disease process is more advanced (HR = 0.53; 95% CI 0.37-0.75; p < 0.001), but not in those with 0 or 1 factor (HR = 0.88; 95% CI 0.59-1.31; p = 0.535). Ultimately, Dr. Panza and colleagues devised an algorithm to aid in deciding on revascularization or medical therapy for patients with ischemic cardiomyopathy.
It seems that we finally have a solution from the STICH trial, according to Clyde W. Yancy, MD, MSc, in an accompanying editorial: "Higher-risk cohorts did better with surgery, and lower-risk cohorts did better with medical therapy." However, Dr. Yancy added, it is not clear which of the prognostic factors predicted the observed response to surgical therapy.
Panza JA, Velazquez EJ, She L, et al. J Am Coll Cardiol. 2014;64:553-61.
Yancy CW. J Am Coll Cardiol. 2014;64:562-4.
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