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Burden of medical co-morbidities and benefit from surgical revascularization in patients with ischaemic cardiomyopathy.

ABSTRACT: AIMS:The landmark STICH trial found that surgical revascularization compared to medical therapy alone improved survival in patients with heart failure (HF) of ischaemic aetiology and an ejection fraction (EF) ??35%. However, the interaction between the burden of medical co-morbidities and the benefit from surgical revascularization has not been previously described in patients with ischaemic cardiomyopathy. METHODS AND RESULTS:The STICH trial (ClinicalTrials.gov Identifier: NCT00023595) enrolled patients ??18?years of age with coronary artery disease amenable to coronary artery bypass grafting (CABG) and an EF ??35%. Eligible participants were randomly assigned 1:1 to receive medical therapy (MED) (n?=?602) or MED/CABG (n?=?610). A modified Charlson co-morbidity index (CCI) based on the availability of data and study definitions was calculated by summing the weighted points for all co-morbid conditions. Patients were divided into mild/moderate (CCI 1-4) and severe (CCI ??5) co-morbidity. Cox proportional hazards models were used to evaluate the association between CCI and outcomes and the interaction between severity of co-morbidity and treatment effect. The study population included 349 patients (29%) with a mild/moderate CCI score and 863 patients (71%) with a severe CCI score. Patients with a severe CCI score had greater functional limitations based on 6-min walk test and impairments in health-related quality of life as assessed by the Kansas City Cardiomyopathy Questionnaire. A total of 161 patients (Kaplan-Meier rate?=?50%) with a mild/moderate CCI score and 579 patients (Kaplan-Meier rate?=?69%) with a severe CCI score died over a median follow-up of 9.8?years. After adjusting for baseline confounders, patients with a severe CCI score were at higher risk for all-cause mortality (hazard ratio 1.44, 95% confidence interval 1.19-1.74; P?

SUBMITTER: Ambrosy AP

PROVIDER: S-EPMC6818499 | biostudies-literature | 2019 Mar

REPOSITORIES: biostudies-literature

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Burden of medical co-morbidities and benefit from surgical revascularization in patients with ischaemic cardiomyopathy.

Ambrosy Andrew P AP Stevens Susanna R SR Al-Khalidi Hussein R HR Rouleau Jean L JL Bouabdallaoui Nadia N Carson Peter E PE Adlbrecht Christopher C Cleland John G F JGF Dabrowski Rafal R Golba Krzysztof S KS Pina Ileana L IL Sueta Carla A CA Roy Ambuj A Sopko George G Bonow Robert O RO Velazquez Eric J EJ

European journal of heart failure 20190130 3

<h4>Aims</h4>The landmark STICH trial found that surgical revascularization compared to medical therapy alone improved survival in patients with heart failure (HF) of ischaemic aetiology and an ejection fraction (EF) ≤ 35%. However, the interaction between the burden of medical co-morbidities and the benefit from surgical revascularization has not been previously described in patients with ischaemic cardiomyopathy.<h4>Methods and results</h4>The STICH trial (ClinicalTrials.gov Identifier: NCT000 ...[more]

PMID: 30698316

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Project description:Aims:Hypertension (HTN) is a well-known contributor to cardiovascular disease, including heart failure (HF) and coronary artery disease, and is the leading risk factor for premature death world-wide. A J- or U-shaped relationship has been suggested between blood pressure (BP) and clinical outcomes in different studies. However, there is little information about the significance of BP on the outcomes of patients with coronary artery disease and left ventricular dysfunction. This study aimed to determine the relationship between BP and mortality outcomes in patients with ischaemic cardiomyopathy. Methods and results:The influence of BP during a median follow-up of 9.8?years was studied in a total of 1212 patients with ejection fraction ?35% and coronary disease amenable to coronary artery bypass grafting (CABG) who were randomized to CABG or medical therapy alone (MED) in the STICH (Surgical Treatment for Ischaemic Heart Failure) trial. Landmark analyses were performed starting at 1, 2, 3, 4, and 5?years after randomization, in which previous systolic BP values were averaged and related to subsequent mortality through the end of follow-up with a median of 9.8?years. Neither a previous history of HTN nor baseline BP had any significant influence on long-term mortality outcomes, nor did they have a significant interaction with MED or CABG treatment. The landmark analyses showed a progressive U-shaped relationship that became strongest at 5?years (?2 and P-values: 7.08, P?=?0.069; 8.72, P?=?0.033; 9.86; P?=?0.020; 8.31, P?=?0.040; 14.52, P?=?0.002; at 1, 2, 3, 4, and 5-year landmark analyses, respectively). The relationship between diastolic BP (DBP) and outcomes was similar. The most favourable outcomes were observed in the SBP range 120-130, and DBP 75-85?mmHg, whereas lower and higher BP were associated with worse outcomes. There were no differences in BP-lowering medications between groups. Conclusion:A strong U-shaped relationship between BP and mortality outcomes was evident in ischaemic HF patients. The results imply that the optimal SBP might be in the range 120-130?mmHg after intervention, and possibly be subject to pharmacologic action regarding high BP. Further, low BP was a marker of poor outcomes that might require other interactions and treatment strategies. Clinical Trial Registration:URL: http://www.clinicaltrials.gov. Unique identifier: NCT00023595.

Dataset Information

Burden of medical co-morbidities and benefit from surgical revascularization in patients with ischaemic cardiomyopathy.

Publications

Burden of medical co-morbidities and benefit from surgical revascularization in patients with ischaemic cardiomyopathy.

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