{"id":7404,"date":"2011-04-04T09:00:54","date_gmt":"2011-04-04T13:00:54","guid":{"rendered":"http:\/\/blogs.nejm.org\/cardioexchange\/?p=7404"},"modified":"2011-07-19T17:44:28","modified_gmt":"2011-07-19T21:44:28","slug":"stich-illuminates-cabg-in-heart-failure-finally","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/cardioexchange\/2011\/04\/04\/stich-illuminates-cabg-in-heart-failure-finally\/","title":{"rendered":"STICH Illuminates CABG in Heart Failure, Finally"},"content":{"rendered":"<p>After a very long wait, the Surgical Treatment for Ischemic Heart  Failure (STICH) trial has finally shed light on the common but poorly  understood use of CABG in heart failure patients with ischemic heart  disease. The results were presented by Eric Velazquez at the ACC and  <a href=\"http:\/\/www.nejm.org\/doi\/full\/10.1056\/NEJMoa1100356\">published simultaneously in the <em>New England Journal of Medicine<\/em><\/a>.<\/p>\n<p>Some 1212 patients with an ejection fraction of 35% or less and coronary  artery disease were randomized to medical therapy plus CABG\u00a0 or medical therapy alone. At 56 months&#8217;  median follow-up. the death rate (the primary endpoint of the study) was  41% in the medical therapy group versus 36% in the CABG group (HR with  CABG: 0.86, CI 0.72-1.04, p=0.12).<\/p>\n<ul>\n<li>Cardiovascular death occurred in 33% of the medical therapy group  versus 28% of the CABG group (HR 0.81, CI 0.66-1.00, p=0.05).<\/li>\n<li>The rate of death plus hospitalization for cardiovascular causes was  68% in the medical therapy group versus 58% in the CABG group (HR 0.74,  CI 0.64-0.85, p&lt;0.001).<\/li>\n<\/ul>\n<p>Some 100 patients in the medical therapy group ended up having CABG during follow-up; 555 patients in the CABG group actually  underwent surgery.<\/p>\n<p>With the exception of 30-day mortality, secondary clinical  outcomes favored CABG. As expected, CABG resulted in an early risk, so  that for the first 2 years after randomization the risk for death was  higher in the surgical group.<\/p>\n<p>The investigators had initially planned to enroll 2000 patients, but  slower than desired enrollment led them to adjust the trial, so that  fewer patients were followed for a longer period in order to accumulate  enough endpoints.<\/p>\n<p>The authors cautioned that &#8220;when the analysis in any trial fails to  detect a significant difference between treatment groups with respect to  the primary outcome, analyses of secondary outcomes showing a benefit  must inevitably be considered to be somewhat provisional.&#8221;<\/p>\n<p><strong>STICH Myocardial Viability Substudy<\/strong><\/p>\n<p>A myocardial viability substudy of STICH was presented immediately following  the main study and was also <a href=\"http:\/\/www.nejm.org\/doi\/full\/10.1056\/NEJMoa1100358\">published simultaneously in the <em>New  England Journal of Medicine<\/em><\/a>. First author Robert Bonow said that  physicians often use myocardial viability tests to determine whether  patients with coronary artery disease and LV dysfunction should undergo  CABG, but that this strategy has never been tested.<\/p>\n<p>In the substudy, 601 patients who had already undergone myocardial  viability testing were randomized to either medical therapy plus CABG or medical therapy alone. The  death rate was 37% among the 487 patients with viable myocardium and  51% among the 114 patients without viable myocardium (HR for patients  with viable myocardium, 0.64, CI 0.48-0.86, p=0.003). However, this  association lost all statistical significance after adjustment for other  baseline characteristics.<\/p>\n<p>The authors write that their results indicate &#8220;that assessment of  myocardial viability alone should not be the deciding factor in  selecting the best therapy for these patients.&#8221;<\/p>\n<p><strong>Editorial<\/strong><\/p>\n<p>James Fang, <a href=\"http:\/\/www.nejm.org\/doi\/full\/10.1056\/NEJMe1103414\">in an accompanying editorial<\/a> entitled &#8220;Underestimating  Medical Therapy for Coronary Disease &#8230; Again,&#8221; writes that patients  like those enrolled in the STICH trial should receive aggressive medical  therapy and that revascularization &#8220;should be carefully weighed but can  be safely deferred,&#8221; though it should be offered to those with  &#8220;persistent or progressive symptoms.&#8221;<\/p>\n<p><em>For more of our ACC.11 coverage of late-breaking clinical trials, interviews with the authors of the most important research, and blogs from our fellows on the most interesting presentations at the meeting, check out our <a href=\"http:\/\/blogs.nejm.org\/cardioexchange\/acc-11-cardioexchange-coverage-roundup\/\">Coverage Roundup<\/a>.<\/em><\/p>\n","protected":false},"excerpt":{"rendered":"<p>After a very long wait, the Surgical Treatment for Ischemic Heart Failure (STICH) trial has finally shed light on the common but poorly understood use of CABG in heart failure patients with ischemic heart disease. The results were presented by Eric Velazquez at the ACC and published simultaneously in the New England Journal of Medicine. [&hellip;]<\/p>\n","protected":false},"author":196,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[20,14],"tags":[231,287,779],"class_list":["post-7404","post","type-post","status-publish","format-standard","hentry","category-cardiac-surgery","category-heart-failure","tag-cabg","tag-heart-failure-2","tag-lv-dysfunction"],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/7404","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/users\/196"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/comments?post=7404"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/7404\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/media?parent=7404"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/categories?post=7404"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/tags?post=7404"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}