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Optimal medical therapy with or without surgical revascularization and long-term outcomes in ischemic cardiomyopathy

Published:January 06, 2021DOI:https://doi.org/10.1016/j.jtcvs.2020.12.094

      Abstract

      Objectives

      Optimal medical therapy in patients with heart failure and coronary artery disease is associated with improved outcomes. However, whether this association is influenced by the performance of coronary artery bypass grafting is less well established. Thus, the aim of this study was to determine the possible relationship between coronary artery bypass grafting and optimal medical therapy and its effect on the outcomes of patients with ischemic cardiomyopathy.

      Methods

      The Surgical Treatment for Ischemic Heart Failure trial randomized 1212 patients with coronary artery disease and left ventricular ejection fraction 35% or less to coronary artery bypass grafting with medical therapy or medical therapy alone with a median follow-up over 9.8 years. For the purpose of this study, optimal medical therapy was collected at baseline and 4 months, and defined as the combination of 4 drugs: angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, beta-blocker, statin, and 1 antiplatelet drug.

      Results

      At baseline and 4 months, 58.7% and 73.3% of patients were receiving optimal medical therapy, respectively. These patients had no differences in important parameters such as left ventricular ejection fraction and left ventricular volumes. In a multivariable Cox model, optimal medical therapy at baseline was associated with a lower all-cause mortality (hazard ratio, 0.78; 95% confidence interval, 0.66-0.91; P = .001). When landmarked at 4 months, optimal medical therapy was also associated with a lower all-cause mortality (hazard ratio, 0.82; 95% confidence interval, 0.62-0.99; P = .04). There was no interaction between the benefit of optimal medical therapy and treatment allocation.

      Conclusions

      Optimal medical therapy was associated with improved long-term survival and lower cardiovascular mortality in patients with ischemic cardiomyopathy and should be strongly recommended.

      Graphical abstract

      Key Words

      Abbreviations and Acronyms:

      ACEI (angiotensin-converting enzyme inhibitor), ARB (angiotensin receptor blocker), CABG (coronary artery bypass grafting), CAD (coronary artery disease), CV (cardiovascular), HF (heart failure), KCCQ (Kansas City Cardiomyopathy Questionnaire), LV (left ventricular), LVEF (left ventricular ejection fraction), MI (myocardial infarction), NYHA (New York Heart Association), OMT (optimal medical therapy), PCI (percutaneous coronary intervention), STICH (Surgical Treatment for Ischemic Heart Failure)
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      Linked Article

      • Commentary: A stitch in time saves nine, but medical therapy makes that stitch shine
        The Journal of Thoracic and Cardiovascular SurgeryVol. 164Issue 6
        • Preview
          Ischemic cardiomyopathy (ICM) is a leading cause of morbidity and mortality across the globe, with a rapidly growing number of affected patients in the US and a poor prognosis overall.1 Median survival is not substantially greater than 5 years in patients with ICM and reduced ejection fraction (EF).2 Although primary prevention of coronary artery disease (CAD) is the sole hope of effectively lessening the societal burden of this disease, effective secondary prevention can preserve some quality and quantity of life in patients diagnosed with ICM.
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      • Commentary: Just what the doctor ordered: The as-yet unrealized gains of optimal medical therapy for ischemic cardiomyopathy
        The Journal of Thoracic and Cardiovascular SurgeryVol. 164Issue 6
        • Preview
          In their post hoc analysis of data obtained from the Surgical Treatment for Ischemic Heart Failure (STICH) trial, Farsky and colleagues1 substantiate the benefit of optimal medical therapy (OMT) on long-term survival after surgical coronary revascularization in patients suffering from ischemic cardiomyopathy. This finding is particularly important given the surprisingly low adherence to OMT and attenuated long-term survival rates in these high-risk patients.
        • Full-Text
        • PDF