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
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)To read this article in full you will need to make a payment
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Article info
Publication history
Published online: January 06, 2021
Accepted:
December 14,
2020
Received in revised form:
December 2,
2020
Received:
July 26,
2020
Footnotes
This work was supported by Grants U01HL69015, U01HL69013, and RO1HL105853 from the National Institutes of Health and National Heart, Lung, and Blood Institute. This work is solely the responsibility of the authors and does not necessarily represent the official views of the National Heart, Lung, and Blood Institute or National Institutes of Health.
There is no additional Institutional Review Board approval required for this analysis because this is a post hoc analysis based on the existing STICH database, that is, no new data are collected and consent had been obtained from every patient in the STICH trial.
Clinical Trial Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT00023595.
Working Group: Rafal Dabrowski, MD, PhD,h Ljubomir Djokovic, MD,i Mark Drazner, MD,j Haissam Haddad, MD,k Imtiaz S. Ali, MD,l Matyas Keltai, MD,m Ajay Naik, MD,n George Sopko, MD,o Krzysztof Golba, MD,p Bert Andersson, MD,q Peter Carson, MD,r and Tomasz Kukulski, MDs
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© 2021 by The American Association for Thoracic Surgery
ScienceDirect
Access this article on ScienceDirectLinked Article
- Commentary: A stitch in time saves nine, but medical therapy makes that stitch shineThe Journal of Thoracic and Cardiovascular SurgeryVol. 164Issue 6
- PreviewIschemic 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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- PreviewIn 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.
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