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Evevident
Original paper
2016NEJMCardiology

STICH/STICHES

Coronary-Artery Bypass Surgery in Patients with Ischemic Cardiomyopathy

RCTIschemic cardiomyopathy

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Overview

In ischemic cardiomyopathy with EF <=35% and CABG-amenable CAD, CABG plus medical therapy reduced 10-year mortality versus medical therapy alone.

Clinical takeaway

STICH was neutral for all-cause mortality at the original follow-up, but STICHES showed a durable 10-year survival benefit. For selected patients with ischemic LV dysfunction and surgically suitable CAD, CABG is the revascularization strategy with long-term survival data.

Key result

All-cause death at 10 years: 58.9% with CABG plus medical therapy vs 66.1% with medical therapy alone; HR 0.84.

Practice impact

Consider CABG for selected patients with ischemic cardiomyopathy, severe LV dysfunction, and graftable coronary anatomy when operative risk is acceptable.

Evidence

Study design

Randomized, open-label, multicenter surgical strategy trial with extended follow-up.

Enrollment

1,212

Follow-up

Median 9.8 years.

Geography

Multinational

Clinical question

Does CABG added to medical therapy improve long-term survival in patients with ischemic cardiomyopathy and severe LV systolic dysfunction?

Population

  • Patients with coronary artery disease amenable to CABG and left ventricular ejection fraction of 35% or less.

Intervention

CABG plus medical therapy.

Comparator

Medical therapy alone.

Primary outcome

Death from any cause during extended follow-up.

CABG plus medical therapy reduced all-cause death over 10 years compared with medical therapy alone.

Hazard ratio / 0.84 / CI 95% CI 0.73-0.97 / p=0.02

Key results

  • All-cause death: 58.9% with CABG vs 66.1% with medical therapy; HR 0.84; 95% CI 0.73-0.97; p=0.02.
  • Cardiovascular death: 40.5% with CABG vs 49.3% with medical therapy; HR 0.79; 95% CI 0.66-0.93; p=0.006.
  • Death or cardiovascular hospitalization: 76.6% with CABG vs 87.0% with medical therapy; HR 0.72; 95% CI 0.64-0.82; p<0.001.

Harms

  • CABG benefit must be weighed against perioperative surgical risk.

Clinical Use

When to cite

  • When explaining why CABG can be prognostic therapy in selected ischemic cardiomyopathy patients.

Practice impact

  • Supports CABG evaluation in appropriate ischemic cardiomyopathy patients with EF <=35% and graftable CAD.
  • Helps distinguish CABG survival data from stable-CAD PCI trials.

Applicability

  • Most applicable to patients with ischemic LV systolic dysfunction, acceptable operative risk, and coronary anatomy suitable for CABG.

Limitations

  • Open-label surgical strategy trial with crossover and selection constraints.
  • Survival benefit became clear only with long-term follow-up.
  • Does not show that PCI provides the same prognostic benefit.

Common misinterpretations

  • Do not cite STICH/STICHES as proof that any revascularization strategy improves survival in stable ischemic cardiomyopathy.

Related evidence

COURAGE - ContextISCHEMIA - Context

Citation

Velazquez EJ, Lee KL, Jones RH, et al. Coronary-Artery Bypass Surgery in Patients with Ischemic Cardiomyopathy. N Engl J Med. 2016;374(16):1511-1520. doi:10.1056/NEJMoa1602001

Death from any cause was significantly lower over 10 years among patients who underwent CABG.