Burden of medical co-morbidities and benefit from surgical revascularization in patients with ischaemic cardiomyopathy.

Published

Journal Article

AIMS: The landmark STICH trial found that surgical revascularization compared to medical therapy alone improved survival in patients with heart failure (HF) of ischaemic aetiology and an ejection fraction (EF) ≤ 35%. However, the interaction between the burden of medical co-morbidities and the benefit from surgical revascularization has not been previously described in patients with ischaemic cardiomyopathy. METHODS AND RESULTS: The STICH trial (ClinicalTrials.gov Identifier: NCT00023595) enrolled patients ≥ 18 years of age with coronary artery disease amenable to coronary artery bypass grafting (CABG) and an EF ≤ 35%. Eligible participants were randomly assigned 1:1 to receive medical therapy (MED) (n = 602) or MED/CABG (n = 610). A modified Charlson co-morbidity index (CCI) based on the availability of data and study definitions was calculated by summing the weighted points for all co-morbid conditions. Patients were divided into mild/moderate (CCI 1-4) and severe (CCI ≥ 5) co-morbidity. Cox proportional hazards models were used to evaluate the association between CCI and outcomes and the interaction between severity of co-morbidity and treatment effect. The study population included 349 patients (29%) with a mild/moderate CCI score and 863 patients (71%) with a severe CCI score. Patients with a severe CCI score had greater functional limitations based on 6-min walk test and impairments in health-related quality of life as assessed by the Kansas City Cardiomyopathy Questionnaire. A total of 161 patients (Kaplan-Meier rate = 50%) with a mild/moderate CCI score and 579 patients (Kaplan-Meier rate = 69%) with a severe CCI score died over a median follow-up of 9.8 years. After adjusting for baseline confounders, patients with a severe CCI score were at higher risk for all-cause mortality (hazard ratio 1.44, 95% confidence interval 1.19-1.74; P < 0.001). There was no interaction between CCI score and treatment effect on survival (P = 0.756). CONCLUSIONS: More than 70% of patients had a severe burden of medical co-morbidities at baseline, which was independently associated with increased risk of death. There was not a differential benefit of surgical revascularization with respect to survival based on severity of co-morbidity.

Full Text

Duke Authors

Cited Authors

  • Ambrosy, AP; Stevens, SR; Al-Khalidi, HR; Rouleau, JL; Bouabdallaoui, N; Carson, PE; Adlbrecht, C; Cleland, JGF; Dabrowski, R; Golba, KS; Pina, IL; Sueta, CA; Roy, A; Sopko, G; Bonow, RO; Velazquez, EJ; STICH Trial Investigators,

Published Date

  • March 2019

Published In

Volume / Issue

  • 21 / 3

Start / End Page

  • 373 - 381

PubMed ID

  • 30698316

Pubmed Central ID

  • 30698316

Electronic International Standard Serial Number (EISSN)

  • 1879-0844

Digital Object Identifier (DOI)

  • 10.1002/ejhf.1404

Language

  • eng

Conference Location

  • England