title: Extent of coronary and myocardial disease and benefit from surgical revascularization in ischemic LV dysfunction [Corrected].
abstract: BACKGROUND
  Patients with ischemic left ventricular dysfunction have higher operative risk with coronary artery bypass graft surgery (CABG). However, those whose early risk is surpassed by subsequent survival benefit have not been identified.
  
  
  OBJECTIVE
  This study sought to examine the impact of anatomic variables associated with poor prognosis on the effect of CABG in ischemic cardiomyopathy.
  
  
  METHODS
  All 1,212 patients in the STICH (Surgical Treatment of IsChemic Heart failure) surgical revascularization trial were included. Patients had coronary artery disease (CAD) and ejection fraction (EF) of ≤35% and were randomized to receive CABG plus medical therapy or optimal medical therapy (OMT) alone. This study focused on 3 prognostic factors: presence of 3-vessel CAD, EF below the median (27%), and end-systolic volume index (ESVI) above the median (79 ml/m(2)). Patients were categorized as having 0 to 1 or 2 to 3 of these factors.
  
  
  RESULTS
  Patients with 2 to 3 prognostic factors (n = 636) had reduced mortality with CABG compared with those who received OMT (hazard ratio [HR]: 0.71; 95% confidence interval [CI]: 0.56 to 0.89; p = 0.004); CABG had no such effect in patients with 0 to 1 factor (HR: 1.08; 95% CI: 0.81 to 1.44; p = 0.591). There was a significant interaction between the number of factors and the effect of CABG on mortality (p = 0.022). Although 30-day risk with CABG was higher, a net beneficial effect of CABG relative to OMT was observed at >2 years in patients with 2 to 3 factors (HR: 0.53; 95% CI: 0.37 to 0.75; p<0.001) but not in those with 0 to 1 factor (HR: 0.88; 95% CI: 0.59 to 1.31; p = 0.535).
  
  
  CONCLUSIONS
  Patients with more advanced ischemic cardiomyopathy receive greater benefit from CABG. This supports the indication for surgical revascularization in patients with more extensive CAD and worse myocardial dysfunction and remodeling. (Comparison of Surgical and Medical Treatment for Congestive Heart Failure and Coronary Artery Disease [STICH]; NCT00023595).
authors.affiliation: Westchester Medical Center and New York Medical College, Valhalla, New York. Electronic address: PanzaJ@wcmc.com.
authors.forename: Julio A
authors.initials: JA
authors.lastname: Panza
authors.affiliation: Duke Clinical Research Institute, Department of Medicine-Cardiology, Duke University School of Medicine, Durham, North Carolina.
authors.forename: Eric J
authors.initials: EJ
authors.lastname: Velazquez
authors.affiliation: Duke Clinical Research Institute, Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC.
authors.forename: Lilin
authors.initials: L
authors.lastname: She
authors.affiliation: Duke Clinical Research Institute, Department of Surgery-Cardiothoracic, Duke University School of Medicine, Durham, North Carolina.
authors.forename: Peter K
authors.initials: PK
authors.lastname: Smith
authors.affiliation: InCor Heart Institute, University of São Paulo Medical School, São Paulo, Brazil.
authors.forename: José C
authors.initials: JC
authors.lastname: Nicolau
authors.affiliation: University Hospital Favaloro Foundation, Buenos Aires, Argentina.
authors.forename: Roberto R
authors.initials: RR
authors.lastname: Favaloro
authors.affiliation: Belgrade University School of Medicine, Belgrade, Serbia.
authors.forename: Sinisa
authors.initials: S
authors.lastname: Gradinac
authors.affiliation: Department of Cardiology, Medical University of Lodz, Lodz, Poland.
authors.forename: Lukasz
authors.initials: L
authors.lastname: Chrzanowski
authors.affiliation: Centre for Chronic Disease Control, New Delhi, India.
authors.forename: Dorairaj
authors.initials: D
authors.lastname: Prabhakaran
authors.affiliation: Foothills Medical Centre, Calgary, Canada.
authors.forename: Jonathan G
authors.initials: JG
authors.lastname: Howlett
authors.affiliation: Medical University of Silesia, Katowice, Poland.
authors.forename: Marek
authors.initials: M
authors.lastname: Jasinski
authors.affiliation: Shands Hospital at the University of Florida, Gainesville, Florida.
authors.forename: James A
authors.initials: JA
authors.lastname: Hill
authors.affiliation: Institute of Cardiology, Warsaw, Poland.
authors.forename: Hanna
authors.initials: H
authors.lastname: Szwed
authors.affiliation: Royal Perth Hospital, Perth, Australia.
authors.forename: Robert
authors.initials: R
authors.lastname: Larbalestier
authors.affiliation: National Heart, Lung, and Blood Institute, Bethesda, Maryland.
authors.forename: Patrice
authors.initials: P
authors.lastname: Desvigne-Nickens
authors.affiliation: Duke Clinical Research Institute, Department of Surgery-Cardiothoracic, Duke University School of Medicine, Durham, North Carolina.
authors.forename: Robert H
authors.initials: RH
authors.lastname: Jones
authors.affiliation: Duke Clinical Research Institute, Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC.
authors.forename: Kerry L
authors.initials: KL
authors.lastname: Lee
authors.affiliation: Montréal Heart Institute, Université de Montréal, Montréal, Quebec, Canada.
authors.forename: Jean L
authors.initials: JL
authors.lastname: Rouleau
mesh_terms: D000368:Aged; D009202:Cardiomyopathies / Q000175:diagnosis / Q000401:mortality / Q000601:surgery; D001026:Coronary Artery Bypass / Q000401:mortality* / Q000639:trends; D003324:Coronary Artery Disease / Q000175:diagnosis / Q000401:mortality* / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D009026:Mortality / Q000639:trends; D011446:Prospective Studies; D016896:Treatment Outcome; D018487:Ventricular Dysfunction, Left / Q000175:diagnosis / Q000401:mortality* / Q000601:surgery*
keywords: coronary artery disease; heart failure; left ventricular dysfunction; myocardial ischemia; outcomes
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