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Ischemic cardiomyopathy

No benefit from bilateral mammary grafts at 5 years

25 Apr, 17 | by flee

Coronary artery bypass grafting (CABG) is an established therapy for obstructive cardiovascular disease and ischemic cardiomyopathy. Utilization of the left-internal mammary artery as a graft has been a particularly successful aspect of CABG due to impressively durable patency rates. Despite this, adoption of bilateral mammary artery grafting has lagged in surgical practice.  The Arterial Revascularization Trial (ART) randomized a total of 3102 patients to either single or bilateral mammary grafting. At five years there were no differences between groups in the rates of death (8.7% vs. 8.4%; P=0.77) or major adverse cardiovascular events including myocardial infarction and stroke (12.2% vs. 12.7%; P=0.69).   Rates of sternal wound infections and sternal reconstruction were significantly higher in the bilateral mammary group (P=0.005) while rates of clinical angina were no different at 5 years.

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Long-term survival benefit for coronary artery bypass grafting surgery in ischemic cardiomyopathy

20 Sep, 16 | by flee

The Surgical Treatment for Ischemic Heart Failure (STICH) trial asked the important question whether coronary artery bypass grafting surgery (CABG) in patients with severe ischemic cardiomyopathy would provide a survival advantage over contemporary medical therapy alone. Reporting 5-year data in 2011, the study reported no significant difference but did demonstrate a tantalizing divergence in survival graphs between 2 and 5 years, which appeared to be increasing with time.  In an extension to the study, 10 year follow-up data is reported.  Out of the original 1212 patients in the study, data was available on 98% of the cohort at long-term follow-up.  Over this long time period the primary outcome of death from any cause occurred in 58.9% in the CABG group and in 66.1% in the medical-therapy group (HR with CABG vs. medical therapy, 0.84; 95% CI, 0.73 to 0.97; P=0.02).  Significant reductions were also seen in cardiovascular death (P=0.006) and hospitalizations for cardiovascular causes (P<0.001) in the CABG group. The overall number needed to treat to prevent 1 death was 14, equating to an overall 16% lower chance of cardiovascular death during the study period and an increase in longevity of approximately 18 months. The effect was consistent across all important sub-group analyses.

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Long-term survival benefit for CABG in ischemic cardiomyopathy

23 Jun, 16 | by flee

The STICH trial asked the important question whether CABG in patients with severe ischemic cardiomyopathy would provide a survival advantage over contemporary medical therapy alone. Reporting 5-year data in 2011, the study reported no significant difference but did demonstrate a tantalizing divergence in survival graphs between 2 and 5 years, which appeared to be increasing with time.  In an extension to the study, 10 year follow-up data is reported.  Out of the original 1212 patients in the study, data was available on 98% of the cohort at long-term follow-up.  Over this long time period the primary outcome of death from any cause occurred in 58.9% in the CABG group and in 66.1% in the medical-therapy group (HR with CABG vs. medical therapy, 0.84; 95% CI, 0.73 to 0.97; P=0.02).  Significant reductions were also seen in cardiovascular death (P=0.006) and hospitalizations for cardiovascular causes (P<0.001) in the CABG group. The overall number needed to treat to prevent 1 death was 14, equating to an overall 16% lower chance of cardiovascular death during the study period and an increase in longevity of approximately 18 months. The effect was consistent across all important sub-group analyses.

Conclusions: In patients with an ischemic cardiomyopathy, revascularization with CABG, when combined with optimal medical therapy confers a long-term survival benefit and a reduction in hospital admissions for cardiovascular causes.  These advantages are not realized immediately, perhaps due to countervailing perioperative risk, but appear sustained to 10 years.

Summarized by James M. McCabe, MD and Steven M. Bradley

Velazquez EJ, Lee KL, Jones RH, Al-Khalidi HR, Hill JA, Panza JA, Michler RE, Bonow RO, Doenst T, Petrie MC, Oh JK, She L, Moore VL, Desvigne-Nickens P, Sopko G, Rouleau JL; STICHES Investigators. Coronary-Artery Bypass Surgery in Patients with Ischemic Cardiomyopathy. N Engl J Med. 2016 Apr 3. [Epub ahead of print]

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