title: Inducible myocardial ischemia and outcomes in patients with coronary artery disease and left ventricular dysfunction.
abstract: OBJECTIVE
  The study objectives were to test the hypotheses that ischemia during stress testing has prognostic value and identifies those patients with coronary artery disease (CAD) with left ventricular (LV) dysfunction who derive the greatest benefit from coronary artery bypass grafting (CABG) compared with medical therapy.
  
  
  BACKGROUND
  The clinical significance of stress-induced ischemia in patients with CAD and moderately to severely reduced LV ejection fraction (EF) is largely unknown.
  
  
  METHODS
  The STICH (Surgical Treatment for IsChemic Heart Failure) trial randomized patients with CAD and EF ≤35% to CABG or medical therapy. In the current study, we assessed the outcomes of those STICH patients who underwent a radionuclide (RN) stress test or a dobutamine stress echocardiogram (DSE). A test was considered positive for ischemia by RN testing if the summed difference score (difference in tracer activity between stress and rest) was ≥4 or if ≥2 of 16 segments were ischemic during DSE. Clinical endpoints were assessed by intention to treat during a median follow-up of 56 months.
  
  
  RESULTS
  Of the 399 study patients (51 women, mean EF 26 ± 8%), 197 were randomized to CABG and 202 were randomized to medical therapy. Myocardial ischemia was induced during stress testing in 256 patients (64% of the study population). Patients with and without ischemia were similar in age, multivessel CAD, previous myocardial infarction, LV EF, LV volumes, and treatment allocation (all p = NS). There was no difference between patients with and without ischemia in all-cause mortality (hazard ratio: 1.08; 95% confidence interval: 0.77 to 1.50; p = 0.66), cardiovascular mortality, or all-cause mortality plus cardiovascular hospitalization. There was no interaction between ischemia and treatment for any clinical endpoint.
  
  
  CONCLUSIONS
  In CAD with severe LV dysfunction, inducible myocardial ischemia does not identify patients with worse prognosis or those with greater benefit from CABG over optimal medical therapy. (Comparison of Surgical and Medical Treatment for Congestive Heart Failure and Coronary Artery Disease [STICH]; NCT00023595).
authors.affiliation: Division of Cardiology, MedStar Washington Hospital Center, Washington, DC 20010, USA. julio.a.panza@medstar.net
authors.forename: Julio A
authors.initials: JA
authors.lastname: Panza
authors.forename: Thomas A
authors.initials: TA
authors.lastname: Holly
authors.forename: Federico M
authors.initials: FM
authors.lastname: Asch
authors.forename: Lilin
authors.initials: L
authors.lastname: She
authors.forename: Patricia A
authors.initials: PA
authors.lastname: Pellikka
authors.forename: Eric J
authors.initials: EJ
authors.lastname: Velazquez
authors.forename: Kerry L
authors.initials: KL
authors.lastname: Lee
authors.forename: Salvador
authors.initials: S
authors.lastname: Borges-Neto
authors.forename: Pedro S
authors.initials: PS
authors.lastname: Farsky
authors.forename: Robert H
authors.initials: RH
authors.lastname: Jones
authors.forename: Daniel S
authors.initials: DS
authors.lastname: Berman
authors.forename: Robert O
authors.initials: RO
authors.lastname: Bonow
mesh_terms: D017023:Coronary Angiography; D001026:Coronary Artery Bypass / Q000379:methods*; D003324:Coronary Artery Disease / Q000150:complications* / Q000175:diagnosis / Q000628:therapy; D025401:Echocardiography, Stress / Q000379:methods*; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D017202:Myocardial Ischemia / Q000175:diagnosis / Q000209:etiology* / Q000628:therapy; D011379:Prognosis; D011446:Prospective Studies; D012720:Severity of Illness Index; D013318:Stroke Volume; D015912:Thrombolytic Therapy / Q000379:methods*; D018487:Ventricular Dysfunction, Left / Q000145:classification* / Q000175:diagnosis / Q000503:physiopathology
chemical_list: D005343:Fibrinolytic Agents