STICH: resoundingly negative or a signal of benefit? Where next for revascularization in ischemic cardiomyopathy?

Abstract

Cardiovascular Division, St Thomas’ Hospital Campus, King’s College London, London SE1 7EH, UK *Author for correspondence: divaka.perera@kcl.ac.uk The decision of whether or not to perform coronary revascularization in patients with ischemic cardiomyopathy (ICM) remains challenging. The reason for this uncertainty and differing practices between physicians has historically been due to a paucity of randomized data in this area. Multiple large retrospective observational studies have demonstrated a long-term survival benefit with coronary artery bypass grafting (CABG) compared with medical therapy, with the greatest benefit seen in those with the most severe left ventricular dysfunction [1–4]. Despite the relatively large sample sizes of these registries, they are intrinsically limited by their observational nature and, as such, although they suggest a benefit with revascularization, the results should be interpreted with caution. The Surgical Treatment for Ischemic Heart Failure (STICH) trial and the STICH viability substudy were simultaneously published in 2011, filling the long-standing void of randomized data in the role of revascularization in ICM. Understandably, STICH has received a lot of academic attention, with some interpreting the trial as heralding the end of revascularization in ICM but other proponents seeing a signal of hope [5–8]. STICH was a multicenter, nonblinded, randomized controlled trial that enrolled 1212 patients with coronary artery disease (CAD) amenable to CABG and a left ventricular ejection fraction (LVEF) of ≤35% [9]. Patients were randomized in a 1:1 fashion to either CABG in combination with optimal medical therapy (OMT) or OMT alone. The primary outcome measure was all-cause mortality and prespecified secondary outcome measures included: rate of death from cardiovascular causes; all cause mortality; or hospitalization for cardiovascular causes. 610 and 602 patients were randomly assigned to the CABG + OMT group and the OMT group, respectively. At the end of follow-up (mean of 56 months), there was no difference in the primary end point between CABG + OMT or OMT alone (36 vs 41%; HR: 0.86; 95% CI: 0.72–1.04; p = 0.12). Although the primary end point Matthew Lumley1 & Divaka Perera*,1