title: Importance of angina in patients with coronary disease, heart failure, and left ventricular systolic dysfunction: insights from STICH.
abstract: BACKGROUND
  Patients with left ventricular (LV) systolic dysfunction, coronary artery disease (CAD), and angina are often thought to have a worse prognosis and a greater prognostic benefit from coronary artery bypass graft (CABG) surgery than those without angina.
  
  
  OBJECTIVE
  This study investigated: 1) whether angina was associated with a worse prognosis; 2) whether angina identified patients who had a greater survival benefit from CABG; and 3) whether CABG improved angina in patients with LV systolic dysfunction and CAD.
  
  
  METHODS
  We performed an analysis of the STICH (Surgical Treatment for Ischemic Heart Failure) trial, in which 1,212 patients with an ejection fraction ≤35% and CAD were randomized to CABG or medical therapy. Multivariable Cox and logistic models were used to assess long-term clinical outcomes.
  
  
  RESULTS
  At baseline, 770 patients (64%) reported angina. Among patients assigned to medical therapy, all-cause mortality was similar in patients with and without angina (hazard ratio [HR]: 1.05; 95% confidence interval [CI]: 0.79 to 1.38). The effect of CABG was similar whether the patient had angina (HR: 0.89; 95% CI: 0.71 to 1.13) or not (HR: 0.68; 95% CI: 0.50 to 0.94; p interaction = 0.14). Patients assigned to CABG were more likely to report improvement in angina than those assigned to medical therapy alone (odds ratio: 0.70; 95% CI: 0.55 to 0.90; p < 0.01).
  
  
  CONCLUSIONS
  Angina does not predict all-cause mortality in medically treated patients with LV systolic dysfunction and CAD, nor does it identify patients who have a greater survival benefit from CABG. However, CABG does improve angina to a greater extent than medical therapy alone. (Comparison of Surgical and Medical Treatment for Congestive Heart Failure and Coronary Artery Disease [STICH]; NCT00023595).
authors.affiliation: Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Canada.
authors.forename: E Marc
authors.initials: EM
authors.lastname: Jolicœur
authors.affiliation: Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina.
authors.forename: Allison
authors.initials: A
authors.lastname: Dunning
authors.affiliation: IRCCS Policlinico San Donato, Milan, Italy.
authors.forename: Serenella
authors.initials: S
authors.lastname: Castelvecchio
authors.affiliation: National Institute of Cardiology, Warsaw, Poland.
authors.forename: Rafal
authors.initials: R
authors.lastname: Dabrowski
authors.affiliation: National Institutes of Health/National Heart, Lung, and Blood Institute, Bethesda, Maryland.
authors.forename: Myron A
authors.initials: MA
authors.lastname: Waclawiw
authors.affiliation: Golden Jubilee National Hospital, Glasgow, United Kingdom.
authors.forename: Mark C
authors.initials: MC
authors.lastname: Petrie
authors.affiliation: Auckland City Hospital, Auckland, New Zealand.
authors.forename: Ralph
authors.initials: R
authors.lastname: Stewart
authors.affiliation: British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom.
authors.forename: Pardeep S
authors.initials: PS
authors.lastname: Jhund
authors.affiliation: National Institutes of Health/National Heart, Lung, and Blood Institute, Bethesda, Maryland.
authors.forename: Patrice
authors.initials: P
authors.lastname: Desvigne-Nickens
authors.affiliation: Westchester Medical Center and New York Medical College, Valhalla, New York.
authors.forename: Julio A
authors.initials: JA
authors.lastname: Panza
authors.affiliation: Northwestern University Feinberg School of Medicine, Chicago, Illinois.
authors.forename: Robert O
authors.initials: RO
authors.lastname: Bonow
authors.affiliation: Allina Health, Minneapolis, Minnesota.
authors.forename: Benjamin
authors.initials: B
authors.lastname: Sun
authors.affiliation: National Heart Centre, Singapore, Singapore.
authors.forename: Tan Ru
authors.initials: TR
authors.lastname: San
authors.affiliation: Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina.
authors.forename: Hussein R
authors.initials: HR
authors.lastname: Al-Khalidi
authors.affiliation: Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Canada.
authors.forename: Jean L
authors.initials: JL
authors.lastname: Rouleau
authors.affiliation: Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina.
authors.forename: Eric J
authors.initials: EJ
authors.lastname: Velazquez
authors.affiliation: National Heart & Lung Institute, Royal Brompton & Harefield Hospitals, Imperial College, London, United Kingdom. Electronic address: j.cleland@imperial.ac.uk.
authors.forename: John G F
authors.initials: JGF
authors.lastname: Cleland
mesh_terms: D000368:Aged; D000787:Angina Pectoris / Q000175:diagnosis / Q000209:etiology* / Q000401:mortality; D002423:Cause of Death / Q000639:trends; D003324:Coronary Artery Disease / Q000150:complications* / Q000401:mortality / Q000503:physiopathology; D005260:Female; D005500:Follow-Up Studies; D014943:Global Health; D006333:Heart Failure / Q000150:complications* / Q000401:mortality / Q000503:physiopathology; D006801:Humans; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D011446:Prospective Studies; D015996:Survival Rate / Q000639:trends; D013599:Systole; D018487:Ventricular Dysfunction, Left / Q000150:complications* / Q000401:mortality / Q000503:physiopathology
keywords: coronary artery bypass grafting; coronary artery disease; heart failure; mortality