Inducible myocardial ischemia and outcomes in patients with coronary artery disease and left ventricular dysfunction.
Journal Article (Journal Article;Multicenter Study)
OBJECTIVES: 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).
Full Text
Duke Authors
Cited Authors
- Panza, JA; Holly, TA; Asch, FM; She, L; Pellikka, PA; Velazquez, EJ; Lee, KL; Borges-Neto, S; Farsky, PS; Jones, RH; Berman, DS; Bonow, RO
Published Date
- May 7, 2013
Published In
Volume / Issue
- 61 / 18
Start / End Page
- 1860 - 1870
PubMed ID
- 23500234
Pubmed Central ID
- PMC3755503
Electronic International Standard Serial Number (EISSN)
- 1558-3597
Digital Object Identifier (DOI)
- 10.1016/j.jacc.2013.02.014
Language
- eng
Conference Location
- United States