Sex Difference in Patients with Ischemic Heart Failure Undergoing Surgical Revascularization: Results from the STICH Trial

BACKGROUND: Female sex is conventionally considered a risk factor for coronary artery bypass grafting (CABG) and has been included as a poor prognostic factor in multiple cardiac operative risk evaluation scores. We aimed to investigate the association of sex and the long-term benefit of CABG in patients with ischemic left ventricular (LV) dysfunction enrolled in the prospective Surgical Treatment for Ischemic Heart Failure Study (STICH) trial. METHODS: The STICH trial randomized 1212 patients [148 (12%) women and 1064 (88%) men] with CAD and LV ejection fraction (EF)≤ 35% to CABG + medical therapy (MED) versus MED alone. Long-term (10-year) outcomes with each treatment were compared according to sex. RESULTS: At baseline, women were older (63.4 vs 59.3, p=0.016) with higher BMI (27.9 vs 26.7, p=0.001). Women had more CAD risk factors (diabetes 55.4% vs 37.2%, hypertension 70.9% vs 58.6%, hyperlipidemia 70.3% vs 58.9%) except for smoking (13.5% vs 21.8%), and had lower rates of prior CABG (0% vs 3.4%, all p<0.05) than men. Moreover, women had higher New York Heart Association (NYHA) class (Class III/IV 66.2% vs 57.0%), lower 6-min walk capacity (300m vs 350m) and lower Kansas City Cardiomyopathy Questionnaire (KCCQ) overall summary scores (51 vs 63) (all p<0.05) than men. Moreover, women had higher New York Heart Association (NYHA) class (Class III/IV 66.2% vs 57.0%), lower 6-min walk capacity (300m vs 350m) and lower Kansas City Cardiomyopathy Questionnaire (KCCQ) overall summary scores (51 vs 63) (all p<0.05). Over 10-years of follow up, all- cause mortality (49.0% vs 65.8%, adjusted HR 0.67, CI 0.52­0.86, p=0.002) and CV mortality (34.3% vs 52.3%, adjusted HR 0.65, CI 0.48­0.89, p=0.006) were significantly lower in women compared to men. With randomization to CABG + MED vs. MED treatment, there was no significant interaction between sex and treatment group in all-cause mortality, CV mortality, or the composite of all-cause mortality or CV hospitalization (all p>0.05). In addition, surgical deaths were not statistically different (1.5% vs 5.1%, p=0.187) between sexes among patients randomized to CABG per protocol as initial treatment. CONCLUSIONS: Sex is not associated with the effect of CABG + MED vs. MED on all-cause mortality, CV mortality, the composite of death or CV hospitalization, or surgical deaths in patients with ischemic LV dysfunction. Thus, sex should not influence treatment decisions regarding CABG in these patients.

Myocardial viability and impact of surgical ventricular reconstructionon outcomes of patients with severe left ventricular dysfunctionundergoing coronary artery bypass surgery: results of the surgical treatment for ischemic heart failure trial

Objectives: In the Surgical Treatment for Ischemic Heart Failure trial, surgical ventricular reconstruction pluscoronary artery bypass surgery was not associated with a reduction in the rate of death or cardiac hospitalizationcompared with bypass alone. We hypothesized that the absence of viable myocardium identifies patients withcoronary artery disease and left ventricular dysfunction who have a greater benefit with coronary artery bypassgraft surgery and surgical ventricular reconstruction compared with bypass alone.Methods: Myocardial viability was assessed by single photon computed tomography in 267 of the 1000 patientsrandomized to bypass or bypass plus surgical ventricular reconstruction in the Surgical Treatment for IschemicHeart Failure. Myocardial viability was assessed on a per patient basis and regionally according to prespecifiedcriteria.Results: At 3 years, there was no difference in mortality or the combined outcome of death or cardiachospitalization between those with and without viability, and there was no significant interaction between thetype of surgery and the global viability status with respect to mortality or death plus cardiac hospitalization.Furthermore, there was no difference in mortality or death plus cardiac hospitalization between those withand without anterior wall or apical scar, and no significant interaction between the presence of scar in theseregions and the type of surgery with respect to mortality.Conclusions: In patients with coronary artery disease and severe regional left ventricular dysfunction,assessment of myocardial viability does not identify patients who will derive a mortality benefit from addingsurgical ventricular reconstruction to coronary artery bypass graft surgery.

Myocardial viability and impact of surgical ventricular reconstruction on outcomes of patients with severe left ventricular dysfunction undergoing coronary artery bypass surgery: results of the surgical treatment for ischemic heart failure trial

In the Surgical Treatment for Ischemic Heart Failure trial, surgical ventricular reconstruction plus coronary artery bypass surgery was not associated with a reduction in the rate of death or cardiac hospitalization compared with bypass alone. We hypothesized that the absence of viable myocardium identifies patients with coronary artery disease and left ventricular dysfunction who have a greater benefit with coronary artery bypass graft surgery and surgical ventricular reconstruction compared with bypass alone.MethodsMyocardial viability was assessed by single photon computed tomography in 267 of the 1000 patients randomized to bypass or bypass plus surgical ventricular reconstruction in the Surgical Treatment for Ischemic Heart Failure. Myocardial viability was assessed on a per patient basis and regionally according to prespecified criteria.ResultsAt 3 years, there was no difference in mortality or the combined outcome of death or cardiac hospitalization between those with and without viability, and there was no significant interaction between the type of surgery and the global viability status with respect to mortality or death plus cardiac hospitalization. Furthermore, there was no difference in mortality or death plus cardiac hospitalization between those with and without anterior wall or apical scar, and no significant interaction between the presence of scar in these regions and the type of surgery with respect to mortality.ConclusionsIn patients with coronary artery disease and severe regional left ventricular dysfunction, assessment of myocardial viability does not identify patients who will derive a mortality benefit from adding surgical ventricular reconstruction to coronary artery bypass graft surgery.