Key result
In patients with CAD and severe LV dysfunction, inducible myocardial ischemia was not associated with all-cause mortality and did not identify patients who derive greater benefit from CABG.
Why the study?
The clinical significance of stress-induced ischemia in patients with CAD and moderately to severely reduced LV ejection fraction was largely unknown.
Does inducible myocardial ischemia predict all-cause mortality or identify patients who benefit more from CABG in patients with coronary artery disease and severe left ventricular dysfunction?
RCT (n=399)
Core lab investigators blinded to treatment assignment and patient characteristics
Randomized to CABG or medical therapy
Yes
Does inducible myocardial ischemia predict all-cause mortality or identify patients who benefit more from CABG in patients with coronary artery disease and severe left ventricular dysfunction?
Answers are grounded in this paper and cite their sources.
In patients with ischemic cardiomyopathy, inducible myocardial ischemia does not predict worse survival or identify those who derive greater benefit from surgical revascularization.
Objectives To test the hypotheses that ischemia during stress testing has prognostic value and that it identifies those coronary artery disease (CAD) patients with left ventricular (LV) dysfunction who derive the greatest benefit from coronary artery bypass graft surgery (CABG) compared to 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 Surgical Treatment of IsChemic Heart failure (STICH) trial randomized patients with CAD and EF ≤35% to CABG or medical therapy. In this study, we assessed the outcomes of those STICH patients who underwent either a radionuclide (RN) stress test or a dobutamine stress echocardiogram (DSE). A test was considered positive for ischemia by RN 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 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, multi-vessel CAD, previous myocardial infarction, LV EF, LV volumes, and treatment allocation (all p=NS). There was no difference between patients with vs. those without ischemia in all-cause mortality (hazard ratio: 1.08; 95% CI: 0.77–1.50; 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. Clinical Trial ID: ClinicalTrials.gov number, NCT00023595
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Panza et al. (2013) conducted an RCT in Coronary artery disease and severe left ventricular dysfunction (n=399). Inducible myocardial ischemia vs. No inducible myocardial ischemia was evaluated on All-cause mortality (HR 1.08, 95% CI 0.77-1.50, p=0.66). In patients with CAD and severe LV dysfunction, inducible myocardial ischemia was not associated with all-cause mortality and did not identify patients who derive greater benefit from CABG.
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