1. Ischemic Cardiomyopathy

2. Ischemic Cardiomyopathy
“The most common cause of heart failure in
developed countries.”
He J, Ogden LG, Bazzano LA, et al. Risk factors for congestive heart failure in US men
and women: NHANES I epidemiologic follow-up study. Arch Intern Med 2001; 161:996.

3. Definition of Ischemic Cardiomyopathy
“Impairment of left ventricular function that
results from coronary artery disease”

4. Pathogenesis
Irreversible loss of myocardium from prior MI
with ventricular remodeling
AND
Partially reversible loss of contractility due to
reduced function of ischemic but still viable
myocardium (Hibernating Myocardium)

5. Hibernating Myocardium
“Contractile dysfunction in viable myocardium
that improves after revascularization or perhap
medical therapy”
Chareonthaitawee P, Gersh BJ, Araoz PA, Gibbons RJ. J Am Coll Cardiol. 2005 Aug
16;46(4):567-74.

6. http://www.britannica.com/blogs/wp-content/uploads/2011/05/dormouse.jpg

7. “No randomized trials of revascularization in
patients with coronary artery disease with
decrease LVEF”
“Multiple observational study suggesting
improvement in outcome with CABG”

8. Current Recommendation for CABG
in patient with poor LV function

9. 1. Significant left main disease
2. Left main equivalent disease ( ≥ 70 % stenosis
of proximal LAD and Proximal LCX)
3. Proximal LAD stenosis with two or three
vessel disease

10. Coronary-Artery Bypass Surgery in
Patients with Left Ventricular
Dysfunction
(STICH trial)

11. STICH = Surgical Treatment for
Ischemic Heart Failure

12. Methods

13. Study Design
• Non-blinded, Randomized study.
• Sponsored by NHLBI and Abbott Laboratories
• Design to have 90% power to detect a 25%
reduction in mortality with CABG as compared
with medical therapy alone

14. Study Patients
• CAD amenable to CABG
• EF of 35% or less

15. Study Procedures
• CABG is performed by cardiac surgeon in
whom have operative death rate less than 5%
• Patients are followed at 30 days, every 4
months then every 6 months on next year

16. Primary Outcome
• Rate of death from any cause

17. Secondary Outcome
• “Rate of death from CVS cause”
• “Rate of death from any cause or
hospitalization from cardiovascular cause”

18. Statistical Analysis
• Intention to treat analysis
• Kaplan Meier method
• As treated analysis

19. Result

20. Study Population
• 1212 Patients from 22 countries
• 602 has medial therapy
• 610 has CABG + Medical Therapy

21. CABG group
610 Patients
529 (95%) got
surgery
63 also got
mitral valve
repair
Medical Group
602 Patients
100 (17%) end up getting
surgery
1. Progressive symptoms
2. Acute decompensation
3. Family ‘s decision
4. Physician’s decision

22. Follow-up
• 5 of 1212 patients were loss to follow up.
• Median length of follow-up is 56 months

23. Outcome Medical Therapy CABG
Rate of death from any
cause
41 % 36 %
Primary Outcome
Hazard Ratio with CABG 0.86
P Value 0.12

25. Secondary Outcome
Outcome Medical Therapy CABG Hazard Ratio
Death from
cardiovascular
cause
33 % 28 %
0.81
(0.66-1.00)
Death from any
cause or admit for
HF
54 % 48 %
0.84
(0.71-0.98)

28. As-treated analysis
CABG
620 Patients
including cross
over
Medical Management
592 Patients

29. As-treated analysis

30. Limitations
• Non blinded study has an effect on non fatal
outcome
• Trial was design to detect 25% reduction in
mortality with CABG
• Limited power and limited duration of follow-
up