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STICHES: CABG reduces 10-year mortality rate in patients with ischemic cardiomyopathy
CHICAGO — Compared with medical therapy alone, CABG plus medical therapy reduced mortality rates over 10 years in patients with ischemic cardiomyopathy, according to long-term results of the STICHES trial reported at the American College of Cardiology Scientific Session.
Eric J. Velazquez, MD, and colleagues randomly assigned 1,212 patients with left ventricular ejection fraction 35% and CAD suitable for CABG (mean age, 60 years; 12% women) to undergo guideline-directed medical therapy alone or guideline-directed medical therapy plus CABG. Patients were enrolled from July 2002 to May 2007 at 99 sites in 22 countries.
The primary outcome was all-cause mortality. Secondary outcomes included CV death and all-cause death/CV hospitalization. Median follow-up was 9.8 years.
STICHES was an extended follow-up of patients from the STICH trial, which found no differences in mortality rates between the groups at 56 months, although lower rates of CV mortality and mortality plus hospitalization in those assigned CABG.
During the study period, 58.9% of the CABG group died compared with 66.1% of controls (HR = 0.84; 95% CI, 0.73-0.97), Velazquez and colleagues found.
CV death occurred in 40.5% of those in the CABG group and 49.3% of those in the control group (HR = 0.79; 95% CI, 0.66-0.93).
In addition, all-cause death or hospitalization for CV cause occurred in 76.6% of the CABG group and 87% of controls (HR = 0.72; 95% CI, 0.64-0.82).
“CABG was associated with an incremental median survival benefit of nearly 18 months and prevention of one death due to any cause for every 14 patients treated and of one death due to a [CV] cause for every 11 patients treated,” Velazquez, from the division of cardiology at Duke University Medical Center, and colleagues wrote in The New England Journal of Medicine.
The curves continued to separate over the study period, which “resulted from a persistent and perhaps increasing effect size over time, coupled with the enhanced precision of estimates afforded by the greater number of events,” the researchers wrote. “It appears that the operative risk associated with CABG is offset by a durable effect that translates into increasing clinical benefit to at least 10 years.” – by Erik Swain
Reference:
Velazquez EJ, et al. Featured Clinical Research I. Presented at: American College of Cardiology Scientific Session; April 2-4, 2016; Chicago.
Velazquez EJ, et al. N Engl J Med. 2016;doi:10.1056/NEJMoa1602001.
Disclosure: The trial was funded by the NIH. Velazquez reports receiving grant support from Abbott Laboratories, Alnylam, Medtronic and Pfizer; grant support and personal fees from Amgen and Novartis; and personal fees from Merck and Spire Learning. Please see the full study for a list of the other researchers’ relevant financial disclosures.
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The STICH trial, published in 2011, did not show a benefit to CABG as compared with medical therapy for the treatment of severe multivessel CAD and LV dysfunction. These initial results gave us pause. It left us a bit uncertain about how best to treat patients with ischemic cardiomyopathy. The 10-year results of STICH demonstrated a significant reduction of the primary endpoint of all-cause mortality among patients randomized to CABG. This long-term follow-up study is very helpful, in that it tells us that patients with CAD and LV dysfunction do show a benefit from aggressive revascularization, although one needs to “get through” the initial surgery and recovery period. These results confirm what most cardiologists already believe. Now, when we send our 40-year-old patients with multivessel disease and cardiomyopathy for surgery, we can do this with confidence, as the decision is supported by clinical evidence of a benefit to this approach.