1. Original Article
Myocardial Viability and Survival in
Ischemic Left Ventricular Dysfunction
Robert O. Bonow, M.D., Gerald Maurer, M.D., Kerry L. Lee, Ph.D., Thomas A.
Holly, M.D., Philip F. Binkley, M.D., Patrice Desvigne-Nickens, M.D., Jaroslaw
Drozdz, M.D., Ph.D., Pedro S. Farsky, M.D., Arthur M. Feldman, M.D., Torsten
Doenst, M.D., Ph.D., Robert E. Michler, M.D., Daniel S. Berman, M.D., Jose C.
Nicolau, M.D., Ph.D., Patricia A. Pellikka, M.D., Krzysztof Wrobel, M.D., Nasri
Alotti, M.D., Ph.D., Federico M. Asch, M.D., Liliana E. Favaloro, M.D., Lilin She,
Ph.D., Eric J. Velazquez, M.D., Robert H. Jones, M.D., and Julio A. Panza, M.D.
for the STICH Trial Investigators

2. Background
Left ventricular dysfunction secondary in patients with
coronary artery disease is not always an irreversible
process
LV function can improve substantially in patients after
CABG
Identifying this subgroup of patients remains the holy
grail of viability research
The common clinical practice of not offering CABG to
patients with LV dysfunction and nonviable scar on
noninvasive studies in not justified by published data

3. Objective
In this substudy of the STICH trial, we report the
outcome of patients who were randomly
assigned to receive medical therapy alone or
medical therapy + CABG who also underwent
assessment of myocardial viability

4. Viability Hypothesis
In this prospective substudy, we tested the
hypothesis that assessment of myocardial
viability identifies patients with CAD and LV
dysfunction who have the greatest survival
benefit with CABG compared to aggressive
medical therapy

5. Study Patients
Patients with angiographic documentation of coronary artery
disease amenable to surgical revascularization and with LV
systolic dysfunction (EF < 35%).
Exclusion criteria - left main coronary artery stenosis fo more
than 50%, cardiogenic shock, myocardial infarction within 3
months, and a need for aortic-valve surgery.
Patients were randomly assigned to receive medical therapy
alone or medical therapy plus CABG.
A risk at randomization (RAR) score was calculated for each
patient with the use of an equation derived in an independent
data set that predicts 5-year risk of death without CABG

6. Study Procedures
Initial design of the STICH trial, viability testing with SPECT was
required for the enrollment of patients
This was eventually expanded to make viability testing optional and
allow the use of either SPECT or dobutamine echocardiography
Investigators at all study centers were strongly encouraged to perform
viability testing in every patient, but the decision to perform the test
was left up to the recruiting investigators
For SPECT, patients with viability were degined as those with 11 or
more viable segments on the basis of relative tracer activity
For dobutamine echo, patients with viability were defined as those with
5 or more segments with abnormal resting systolic function but
manifesting contractile reserve during dobutamine administration

7. Viability Study
SPECT protocols
Thallium-201 stress-redistribution-reinjection
Thallium 201 rest-redistribution
Nitrate-enhanced Tc99m perfusion imaging
Dobutamine echo protocols
Stages increase in dobutamine starting at 5 µg/
kg/min

8. Patient Follow-up and
Outcomes
Patients were followed every 4 months for the first year
and every 6 months thereafter
Primary outcome was death from any cause
Secondary end points
Death from cardiovascular cause
Composite of death from any cause
Hospitalization for cardiovascular causes
Intention-to-treat analysis

9. Results
Of 1212 patient enrolled in the hypothesis 1 comparison, 601 who
underwent assessment of viability were included in the analysis
Differences between two groups
Higher percentage of white patients and lower patients of Asian
patients underwent viability study
Patient in the viability study were more likely
To have hyperlipidemia,
To be on optimal medical therapy,
Have lower LVEF and higher LVEDV and LVESV
Have lower blood pressure

10. Study Design

11. Black 31 (2.6) 18 (3.0) 13 (2.1)
Asian 209 (17.2) 29 (4.8) 180 (29.5)
Other 141 (11.6) 54 (9.0) 87 (14.2)
Multiracial 4 (0.3) 4 (0.7) 0 (0.0)
Prior myocardial infarction, no. (%) 934 (77.1) 481 (80.0) 453 (74.1) 0.015
Baseline Characteristics of Patients With and Without
Diabetes, no. (%) 478 (39.4) 224 (37.3) 254 (41.6) 0.126
Stroke, no. (%) 92 (7.6) 53 (8.8) 39 (6.4) 0.109
Hypertension, no. (%) 728 (60.1) 363 (60.4) 365 (59.7) 0.814
Hyperlipidemia, no. (%) 730 (60.3) 403 (67.3) 327 (53.5) <0.001
Viability Test
Current smoker, no. (%) 252 (20.8) 126 (21.0) 126 (20.7) 0.895
Chronic renal insufficiency, no. (%) 94 (7.8) 43 (7.2) 51 (8.3) 0.443
Atrial flutter/fibrillation, no. (%) 153 (12.6) 90 (15.0) 63 (10.3) 0.015
Peripheral vascular disease,no. (%) 184 (15.2) 91 (15.1) 93 (15.2) 0.969
RAR score, mean ± SD 12.7 ± 8.8 12.5 ± 8.8 12.9 ± 8.8 0.311
!"# Previous CABG, no. (%) 36 (3.0) 16 (2.7) 20 (3.3) 0.531
# Bypass graft status, no. (%)
Table S2. Baseline characteristics of patients with and without testing of myocardial viability !"#$%&'($&)#(*#(++,-)&) 35 (97.2) 15 (93.8) 20 (100) 0.444
!"#(++,-)&) 29 (80.6) 14 (87.5) 15 (75.0) 0.426
Previous PCI, no. (%) 156 (12.9) 104 (17.3) 52 (8.5) <0.001
Patients with Patients without Previous ICD, no. (%) 29 (2.4) 16 (2.7) 13 (2.1) 0.543
All patients CAD distribution, no. (%) !"#
Characteristic a viability test a viability test P value #
(n=1212) No. of disease)#.&$$&,$#!/01 0.416
(n=601) (n=611) Table S2. Baseline characteristics of patients with and without testing of 13 (2.1)
myocardial viability
None* 25 (2.1) 12 (2.0)
Age, mean ± SD 60.3 ± 9.3 60.7 ± 9.4 59.9 ± 9.2 0.113
One-vessel 282 (23.2) 152 (25.3) 130 (21.3)
Male, no. (%) 1064 (87.7) 521 (86.7) 543 (88.9) 0.246 Two-vessel 462 (38.2) 221 (36.8) 241 (39.4)
Race, no. (%) <0.001 Three-vessel 442 (36.5) Patients with Patients without
215 (35.8) 227 (37.2)
All patients
White 827 (68.2) 496 (82.5) 331 (54.2) Characteristic
2*(3456,#789#$%&'($4$#!/01##### 826 (68.2) a viability test
389 (64.8) a viability test
437 (71.5) P0.012
value
(n=1212)
Black 31 (2.6) 18 (3.0) 13 (2.1) 7&:%#564'#$%&'($4$#;!0<1= 32 (2.6) (n=601)
14 (2.3) (n=611)
18 (2.9)) 0.506
Asian 209 (17.2) 29 (4.8) 180 (29.5) Age, mean ± SD
Current CCS angina class, no. (%) 60.3 ± 9.3 60.7 ± 9.4 59.9 ± 9.2 0.113
0.023
Other 141 (11.6) 54 (9.0) 87 (14.2) Male, no. (%)
No angina 1064 (87.7)
442 (36.5) 521 (39.3)
236 (86.7) 543 (33.7)
206 (88.9) 0.246
Multiracial 4 (0.3) 4 (0.7) 0 (0.0) Race, no. (%)
I 187 (15.4) 94 (15.6) 93 (15.2) <0.001
Prior myocardial infarction, no. (%) 934 (77.1) 481 (80.0) 453 (74.1) 0.015 II White 827 (43.3)
525 (68.2) 496 (42.1)
253 (82.5) 331 (44.5)
272 (54.2)
Diabetes, no. (%) 478 (39.4) 224 (37.3) 254 (41.6) 0.126 IIIBlack 31 (2.6)
48 (4.0) 18 (3.0)
14 (2.3) 13 (2.1)
34 (5.6)
IV Asian 209 (0.8)
10 (17.2) 29 (4.8)
4 (0.7)) 180(1.0)
6 (29.5)
Stroke, no. (%) 92 (7.6) 53 (8.8) 39 (6.4) 0.109 Other 141 (11.6) 54 (9.0) 87 (14.2)
Hypertension, no. (%) 728 (60.1) 363 (60.4) 365 (59.7) 0.814 Highest NYHA functional class
Hyperlipidemia, no. (%) 730 (60.3) 403 (67.3) 327 (53.5) <0.001 withinMultiracial no. (%)
3 months, 4 (0.3) 4 (0.7) 0 (0.0) 0.231
Prior myocardial infarction, no. (%)
I 934 (5.7)
69 (77.1) 481 (4.5)
27 (80.0) 453 (6.9)
42 (74.1) 0.015
Current smoker, no. (%) 252 (20.8) 126 (21.0) 126 (20.7) 0.895 Diabetes, no. (%)
II 478 (39.4)
438 (36.1) 224 (37.3)
212 (35.3) 254 (41.6)
226 (37.0) 0.126
Chronic renal insufficiency, no. (%) 94 (7.8) 43 (7.2) 51 (8.3) 0.443 Stroke, no. (%)
III 92 (7.6)
540 (44.6) 53 (8.8)
275 (45.8) 39 (6.4)
265 (43.4) 0.109
!"#
Atrial flutter/fibrillation, no. (%) 153 (12.6) 90 (15.0) 63 (10.3) 0.015 # Hypertension, no. (%)
IV 728 (13.6)
165 (60.1) 363(14.5)
87 (60.4) 365(12.8)
78 (59.7) 0.814
Peripheral vascular disease,no. (%) 184 (15.2) 91 (15.1) 93 (15.2) 0.969 Hyperlipidemia,baseline, no. (%)
Medications at no. (%) 730 (60.3) 403 (67.3) 327 (53.5) <0.001
RAR score, mean ± SD 12.7 ± 8.8 12.5 ± 8.8 12.9 ± 8.8 0.311 Current smoker, no. (%)
Beta blocker 252 (20.8)
1036 (85.5) 126 (21.0)
534 (88.9) 126 (20.7)
502 (82.2) 0.895
<0.001
Previous CABG, no. (%) 36 (3.0) 16 (2.7) 20 (3.3) 0.531 Chronic renal insufficiency, no. (%)
ACE inhibitor 94 (7.8)
996 (82.2) 43 (7.2)
514 (85.5) 51 (8.3)
482 (78.9) 0.443
0.002
Bypass graft status, no. (%) Atrial flutter/fibrillation, no. (%)
Angiotensin receptor blocker 153 (12.6)
115 (9.5) 90 (15.0)
46 (7.7) 63 (10.3)
69 (11.3) 0.015
0.031
!"#$%&'($&)#(*#(++,-)&) 35 (97.2) 15 (93.8) 20 (100) 0.444 Peripheral vascular disease,no. (%)
ACE inhibitor or ARB 184 (15.2)
1085 (89.5) 91 (15.1)
554 (92.2) 93 (15.2)
531 (86.9) 0.969
0.003
!"#(++,-)&) 29 (80.6) 14 (87.5) 15 (75.0) 0.426 RAR score, mean ± SD
Statin 12.7 (81.1)
983 ± 8.8 12.5 ± 8.8
508 (84.5) 12.9 ± 8.8
475 (77.7) 0.311
0.003
Previous PCI, no. (%) 156 (12.9) 104 (17.3) 52 (8.5) <0.001 Previous CABG, no. (%)
Aspirin 36 (3.0)
1002 (82.7) 513(2.7)
16 (85.4) 489(3.3)
20 (80.0) 0.531
0.014
Bypass graft status, no. (%)
Digoxin 245 (20.2) 109 (18.1) 136 (22.3) 0.074
Previous ICD, no. (%) 29 (2.4) 16 (2.7) 13 (2.1) 0.543
!"#$%&'($&)#(*#(++,-)&)
Blood pressure, mean ± SD# 35 (97.2) 15 (93.8) 20 (100) 0.444
CAD distribution, no. (%) !"#(++,-)&) 29 (80.6) 14 (87.5) 15 (75.0) 0.426
Systolic (mmHg) 121.2 ± 17.5 119.8 ± 17.3 122.5 ± 17.7 0.003
No. of disease)#.&$$&,$#!/01 0.416 Previous PCI, no. (%)
Diastolic (mmHg) 156 (12.9)
75.5 ± 11.0 104 (17.3)
74.7 ± 10.7 52 (8.5)
76.3 ± 11.3 <0.001
0.022
None* 25 (2.1) 12 (2.0) 13 (2.1) Previous ICD, no. ± SD#
Heart rate, mean (%) 74.9(2.4)
29 ± 14.7 73.3(2.7)
16 ± 12.9 13 (2.1)
76.4 ± 16.1 0.543
<0.001
One-vessel 282 (23.2) 152 (25.3) 130 (21.3) CAD distribution, no. mean ± SD
LV ejection fraction, (%) 0.279 ± 0.087 0.267 ± 0.086 0.290 ± 0.086 <0.001
Two-vessel 462 (38.2) 221 (36.8) 241 (39.4) LVEDVIof disease)#.&$$&,$#!/01
No. (ml/m2), mean ± SD 117.6 ± 39.2 122.8 ± 41.9 110.4 ± 33.9 0.416
<0.001
Three-vessel 442 (36.5) 215 (35.8) 227 (37.2) None*
LVESVI (ml/m2), mean ± SD 85.5(2.1)
25 ± 36.2 91.7(2.0)
12 ± 38.9 13 (2.1)
78.6 ± 31.6 <0.001
2*(3456,#789#$%&'($4$#!/01##### 826 (68.2) 389 (64.8) 437 (71.5) 0.012 One-vessel mean ± SD
Hemoglobin (g/dL), 282 (23.2)
13.8 ± 1.7 152 (25.3)
13.9 ± 1.7 130 (21.3)
13.6 ± 1.8 0.005
7&:%#564'#$%&'($4$#;!0<1= 32 (2.6) 14 (2.3) 18 (2.9)) 0.506 Two-vessel
Creatinine (mg/dL), mean ± SD 462 (38.2)
1.2 ± 0.6 221 (36.8)
1.2 ± 0.7 241 (39.4)
1.2 ± 0.5 0.004
Current CCS angina class, no. (%) 0.023 Three-vessel
BUN (mg/dL), mean ± SD 442 (36.5)
29.3 ± 21.2 215 (35.8)
29.2 ± 19.7 227 (37.2)
29.5 ± 22.3 0.980
No angina 442 (36.5) 236 (39.3) 206 (33.7) 2*(3456,#789#$%&'($4$#!/01##### 826 (68.2) 389 (64.8) 437 (71.5) 0.012
7&:%#564'#$%&'($4$#;!0<1= 32 (2.6) 14 (2.3) 18 (2.9)) 0.506
I 187 (15.4) 94 (15.6) 93 (15.2) *Although some patients had no coronary artery stenosis !75%, all patients had a coronary artery
II 525 (43.3) 253 (42.1) 272 (44.5) Current CCS!50%. class, no. (%)
with stenosis angina 0.023
No angina 442 (36.5) 236 (39.3) 206 (33.7)

12. Baseline Characteristics
Patients with and without myocardial viability

13. !"#
#
Table S5. Baseline characteristics of patients with and without evidence of viable myocardium
All patients Patients with Patients without
with viability myocardial myocardial
Characteristic P value
testing viability* viability*
(n=601) (n=487) (n=114)
Age, mean ± SD 60.7 ± 9.4 60.7 ± 9.5 60.8 ± 8.8 0.891
Male, no. (%) 521 (86.7) 416 (85.4)# 105 (92.1) 0.059
Race, no. (%)# 0.209
White 496 (82.5) 393 (80.7) 103 (90.4)
Black 18 (3.0) 17 (3.5) 1 (0.9)
Asian 29 (4.8) 26 (5.3) 3 (2.6)
Other 54 (9.0) 47 (9.7) 7 (6.1) !"#
Multi-racial# 4 (0.7) 4 (0.8) 0 (0.0) #
Prior myocardial infarction, no. (%) 481 (80.0) 373 (76.6) 108 (94.7) <0.001 #
Diabetes, no. (%) 224 (37.3) 198 (40.7) 26 (22.8) <0.001 Medications at baseline, no. (%)
Stroke, no. (%) 53 (8.8) 42 (8.6) 11 (9.6) 0.728 Beta blocker 534 (88.9) 437 (89.7) 96 (85.0) 0.156
Hypertension, no. (%) 363 (60.4) 312 (64.1) 50 (44.7) <0.001
ACE inhibitor 514 (85.5) 412 (84.6) 102 (89.5) 0.183
Hyperlipidemia, no. (%) 403 (67.3) 326 (67.1) 77 (68.1) 0.828
Angiotensin receptor blocker 46 (7.7) 40 (8.2) 6 (5.3) 0.286
Current smoker, no. (%) 126 (21.0) 108 (22.2) 18 (15.8) 0.131
Chronic renal insufficiency, no. (%) 43 (7.2) 33 (6.8) 10 (8.8) 0.460
ACE inhibitor or ARB 554 (92.2) 446 (91.6) 108 (94.7) 0.259
Atrial flutter/fibrillation, no. (%) 90 (15.0) 74 (15.2) 16 (14.0) 0.755 Statin 508 (84.5) 405 (83.2) 103 (90.4) 0.056
Peripheral vascular disease,no. (%) 91 (15.1) 75 (15.4) 16 (14.0) 0.714 Aspirin 513 (85.4) 414 (85.0) 99 (86.8) 0.618
RAR score, mean ± SD 12.5 ± 8.8 12.4 ± 8.7 12.9 ± 9.3 0.753 Digoxin 109 (18.1) 80 (16.4) 29 (25.4) 0.025
Previous CABG, no. (%) 16 (2.7) 12 (2.5) 4 (3.5) 0.520 Blood pressure, mean ± SD
Bypass graft status, no. (%) Systolic (mmHg) 119.8 ± 17.3 121.1 ± 17.7 114.4 ± 14.3 <0.001
!"#$%&'($&)#(*#(++,-)&) 15 (93.8) 11 (91.7) 4 (100) 1.000 Diastolic (mmHg) 74.7 ± 10.7 74.9 ± 10.9 73.7 ± 9.3 0.447
!"#(++,-)&) 14 (87.5) 10 (83.3) 4 (100) 1.000 Heart rate, mean ± SD# 73.3 ± 12.9 73.3 ± 12.4 73.5 ± 14.7 0.839
Previous PCI, no. (%) 104 (17.3) 77 (15.8) 27 (23.7) 0.045 LV ejection fraction, mean ± SD 0.267 ± 0.086 0.275 ± 0.083 0.229 ± 0.088 <0.001
Previous ICD, no. (%) 16 (2.7) 10 (2.1) 6 (5.3) 0.096 LVEDVI (ml/m2), mean ± SD 122.8 ± 41.9 116.9 ± 36.5 146.5 ± 52.6 <0.001
CAD distribution, no. (%)
LVESVI (ml/m2), mean ± SD 91.7 ± 38.9 85.9 ± 33.2 116.3 ± 50.2 <0.001
No. of diseased vessels !75% 0.957
None 12 (2.0) 9 (1.9) 3 (2.6) Hemoglobin (g/dL), mean ± SD 13.9 ± 1.7 13.9 ± 1.7 14.1 ± 1.6 0.426
One-vessel 152 (25.3) 124 (25.5) 28 (24.6) Creatinine (mg/dL), mean ± SD 1.2 ± 0.7 1.2 ± 0.8 1.2 ± 0.4 0.123
Two-vessel 221 (36.8) 179 (36.8) 42 (36.8) BUN (mg/dL), mean ± SD 29.2 ± 19.7 29.5 ± 20.0 27.3 ± 18.0 0.485
Three-vessel 215 (35.8) 174 (35.8) 41 (36.0)
Proximal LAD stenosis !75% 389 (64.8) 309 (63.6) 80 (70.2) 0.184 ACE = angiotensin converting enzyme; ARB = angiotensin receptor blocker; BUN = blood urea
Left main stenosis .!/012 14 (2.3) 12 (2.5) 2 (1.8) 1.000 nitrogen; CABG = coronary artery bypass graft surgery; CAD = coronary artery disease; CCS =
Current CCS angina class, no. (%) 0.061 Canadian Cardiac Society; EDVI = end-diastolic volume index; ESVI = end-systolic volume index;
No angina 236 (39.3) 202 (41.5) 34 (29.8) ICD = implantable cardioverter defibrillator; LV= left ventricular; NYHA = New York Heart
I 94 (15.6) 68 (14.0) 26 (22.8) Association; RAR = risk at randomization#
II 253 (42.1) 203 (41.7) 50 (43.9)
III 14 (2.3) 11 (2.3) 3 (2.6)
IV 4 (0.7)) 3 (0.6) 1 (0.9)
Highest NYHA functional class 0.055
within 3 months, no. (%)
I 27 (4.5) 24 (4.9) 3 (2.6)
II 212 (35.3) 182 (37.4) 30 (26.3)
III 275 (45.8) 211 (43.3) 64 (56.1)
IV 87 (14.5) 70 (14.4) 17 (14.9)

15. Viability and Mortality
During a median of 5.1 years of follow
up
39% of the total population died
51% of deaths occurred in
patients without myocardial
viability
37% of deaths occurred in
patients with viability
However, after adjustment for other
significant baseline prognostic
variables in a multivariate, viability
status was no longer significantly
associated with the rate of death
(p=0.21)

16. Multivariate Analysis

17. Secondary endpoints
Patients with viability also had lower rates of
secondary endpts
Death from CV causes (hazard ratio, 0.61; 95% CI,
0.44 to 0.84; P=0.003)
Not significant on multivariate analysis
Composite of death or hospitlization for CV causes
(hazard ratio, 0.59; 95% CI, 0.47 to 0.74; P<0.001)
Significant on multivariate analysis

18. Viability and treatment arm

19. CABG versus medical therapy

20. Study Limitations
Viability study was not performed in enrolled
patients in STICH
Viability studies were limited to dobutamine and
SPECT, while MRI and PET studies were
excluded

21. Conclusions
Study demonstrated a significant association
between myocardial viability and outcome, but
this association was non-siginificant when
subjected to a multivariate analysis
Study failed to demonstrate a significant
interaction between myocardial viability and
medical versus surgical treatment