Extent of coronary and myocardial disease and benefit from surgical revascularization in ischemic LV dysfunction [Corrected].
BACKGROUND
Patients with ischemic left ventricular dysfunction have higher operative risk with coronary artery bypass graft surgery (CABG). However, those whose early risk is surpassed by subsequent survival benefit have not been identified.


OBJECTIVES
This study sought to examine the impact of anatomic variables associated with poor prognosis on the effect of CABG in ischemic cardiomyopathy.


METHODS
All 1,212 patients in the STICH (Surgical Treatment of IsChemic Heart failure) surgical revascularization trial were included. Patients had coronary artery disease (CAD) and ejection fraction (EF) of ≤35% and were randomized to receive CABG plus medical therapy or optimal medical therapy (OMT) alone. This study focused on 3 prognostic factors: presence of 3-vessel CAD, EF below the median (27%), and end-systolic volume index (ESVI) above the median (79 ml/m(2)). Patients were categorized as having 0 to 1 or 2 to 3 of these factors.


RESULTS
Patients with 2 to 3 prognostic factors (n = 636) had reduced mortality with CABG compared with those who received OMT (hazard ratio [HR]: 0.71; 95% confidence interval [CI]: 0.56 to 0.89; p = 0.004); CABG had no such effect in patients with 0 to 1 factor (HR: 1.08; 95% CI: 0.81 to 1.44; p = 0.591). There was a significant interaction between the number of factors and the effect of CABG on mortality (p = 0.022). Although 30-day risk with CABG was higher, a net beneficial effect of CABG relative to OMT was observed at >2 years in patients with 2 to 3 factors (HR: 0.53; 95% CI: 0.37 to 0.75; p<0.001) but not in those with 0 to 1 factor (HR: 0.88; 95% CI: 0.59 to 1.31; p = 0.535).


CONCLUSIONS
Patients with more advanced ischemic cardiomyopathy receive greater benefit from CABG. This supports the indication for surgical revascularization in patients with more extensive CAD and worse myocardial dysfunction and remodeling. (Comparison of Surgical and Medical Treatment for Congestive Heart Failure and Coronary Artery Disease [STICH]; NCT00023595).
['Panza|Julio A|JA|', 'Velazquez|Eric J|EJ|', 'She|Lilin|L|', 'Smith|Peter K|PK|', 'Nicolau|José C|JC|', 'Favaloro|Roberto R|RR|', 'Gradinac|Sinisa|S|', 'Chrzanowski|Lukasz|L|', 'Prabhakaran|Dorairaj|D|', 'Howlett|Jonathan G|JG|', 'Jasinski|Marek|M|', 'Hill|James A|JA|', 'Szwed|Hanna|H|', 'Larbalestier|Robert|R|', 'Desvigne-Nickens|Patrice|P|', 'Jones|Robert H|RH|', 'Lee|Kerry L|KL|', 'Rouleau|Jean L|JL|']
D000368:Aged D009202:Cardiomyopathies D001026:Coronary Artery Bypass D003324:Coronary Artery Disease D005260:Female D005500:Follow-Up Studies D006801:Humans D008297:Male D008875:Middle Aged D009026:Mortality D011446:Prospective Studies D016896:Treatment Outcome D018487:Ventricular Dysfunction, Left
left ventricular dysfunction heart failure coronary artery disease myocardial ischemia outcomes