Coronary Artery Bypass Surgery in Patients With Left Ventricular Dysfunction
What is the role of cardiac surgery in the treatment of patients with coronary artery disease and left ventricular systolic dysfunction?
Between July 2002 and May 2007, 1,212 patients in the STICH (Surgical Treatment for Ischemic Heart Failure) trial with an ejection fraction ≤35% and coronary artery disease amenable to coronary artery bypass grafting (CABG) were randomly assigned to medical therapy alone (602 patients) or medical therapy plus CABG (610 patients). The primary outcome was the rate of death from any cause. Major secondary outcomes included the rates of death from cardiovascular causes and of death from any cause or hospitalization for cardiovascular causes. Cumulative event rates were calculated according to the Kaplan–Meier method, with all event or censoring times measured from the time of randomization.
The primary outcome occurred in 244 patients (41%) in the medical therapy group and 218 (36%) in the CABG group (hazard ratio [HR] with CABG, 0.86; 95% confidence interval [CI], 0.72-1.04; p = 0.12). A total of 201 patients (33%) in the medical therapy group and 168 (28%) in the CABG group died from an adjudicated cardiovascular cause (HR with CABG, 0.81; 95% CI, 0.66-1.00; p = 0.05). Death from any cause or hospitalization for cardiovascular causes occurred in 411 patients (68%) in the medical therapy group and 351 (58%) in the CABG group (HR with CABG, 0.74; 95% CI, 0.64-0.85; p < 0.001). By the end of the follow-up period (median, 56 months), 100 patients in the medical therapy group (17%) underwent CABG, and 555 patients in the CABG group (91%) underwent CABG.
The authors concluded that there was no significant difference between medical therapy alone and medical therapy plus CABG with respect to the primary endpoint of death from any cause.
This randomized trial showed that there was no significant difference between medical therapy alone and medical therapy plus CABG in patients with coronary artery disease and left ventricular dysfunction with respect to the primary outcome, the rate of death from any cause. Between-group differences in favor of CABG were seen with respect to the rate of death from cardiovascular causes and the rate of death from any cause or hospitalization for cardiovascular causes in the intention-to-treat analysis. The results of this pivotal trial support the notion that in general, surgery is not superior to optimal medical therapy for ischemic left ventricular dysfunction. Decisions with respect to revascularization (either surgical or percutaneous) should be carefully weighed, but may be safely deferred as treatment plans are individualized and modified over time.
Keywords: Follow-Up Studies, Heart Failure, Coronary Disease, Coronary Artery Bypass, Cardiac Surgical Procedures, Ventricular Dysfunction, Left, Hospitalization
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