coronary artery bypass grafting

CABG Beneficial for Older Patients with Heart Failure and Left Ventricular Systolic Dysfunction

November 28, 2016

Ten-Year Follow-Up Analysis of STICH Trial

Key Takeaways

  • CABG lowered cardiovascular-related mortality for heart failure patients in the STICH trial.
  • Increasing age tends to diminish benefits received from surgical revascularization.
  • Cardiovascular death was higher among younger patients enrolled in STICH at 10 years’ follow-up.
  • While mortality increases with advancing age, CABG plus guideline-directed medical therapy can still be a good choice for older patients.

The Surgical Treatment for Ischemic Heart Failure (STICH) randomized trial sought to assess the potential for improved survival in heart failure (HF) and coronary artery disease (CAD) patients receiving coronary artery bypass grafting (CABG) and guideline-directed medical therapy compared with medical therapy alone. Findings from this initial study showed that mortality from cardiovascular causes (or any cause) was lower among the CABG-receiving group.1

The 10-year extended follow-up study was subsequently performed to examine the long-term effects of CABG in ischemic cardiomyopathy patients. Findings from this study found that patients receiving CABG as well as medical therapy had a significantly lower rate of all-cause mortality or hospitalization than those patients who received only medical therapy.2

Differences seen in this study vary greatly by age, and further examination is necessary to determine the effects of revascularization with CABG in older HF and CAD patients. Considering that increasing age appears to diminish the benefits of surgical revascularization and increases the risk for worse long- and short-term outcomes following CABG, a recent analysis published in Circulation sought to evaluate the 10-year extended follow-up of the STICH trial to discover all-cause mortality in patients of varying ages with HF receiving CABG and guideline-directed medical therapy.3

For this analysis study, patients were divided into four quartiles based on age. These quartiles were as follows:

  • Quartile 1: Age ≤54 years (n=330)
  • Quartile 2: Age ≤60-54 years (n=295)
  • Quartile 3: Age ≤67-60 years (n=279)
  • Quartile 4: Age >67 years (n=308)

Following analysis of the available 10-year data, cardiovascular and all-cause mortality increased with advancing age (Figure 1) in both the medical therapy and CABG groups. Cardiovascular deaths, however, were ranked higher in the younger vs older patients (79% vs 62%, respectively).

Figure 1. Rates of mortality or cardiovascular hospitalizationa
rates of mortality or cardiovascular hospitalization
aData from Petrie MC, Jhund PS, She L, et al3

CABG tended to reduce all-cause mortality more than guideline-directed medical therapy in younger patients; however, the efficacy of CABG on cardiovascular mortality was observed across all quartiles. While there were greater reductions in cardiovascular-related hospitalizations and all-cause death among the youngest quartiles receiving CABG, authors point out that surgical revascularization warrants consideration among HF patients regardless of age.

References:

  1. Velazquez EJ, Lee KL, Deja MA, et al. Coronary-artery bypass surgery in patients with left ventricular dysfunction. New England Journal of Medicine. 2011;364(17):1607-1616.
  2. Velazquez EJ, Lee KL, Jones RH, et al. Coronary-Artery Bypass Surgery in Patients with Ischemic Cardiomyopathy. New England Journal of Medicine. 2016;374(16):1511-1520.
  3. Petrie MC, Jhund PS, She L, et al. Ten-Year Outcomes After Coronary Artery Bypass Grafting According to Age in Patients With Heart Failure and Left Ventricular Systolic Dysfunction: An Analysis of the Extended Follow-Up of the STICH Trial (Surgical Treatment for Ischemic Heart Failure). Circulation. 2016;134(18):1314-1324.

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