Optimal medical therapy use and long-term outcomes in cabg-eligible heart failure patients: insights from the stich trial

ABSTRACT

BACKGROUND: Coronary Artery Bypass Grafting (CABG) reduces mortality in Heart Failure (HF) and coronary artery disease (CAD) patients (pts). There is a paucity of data on the utilization of optimal medical therapy (OMT) in HF and CAD pts after revascularization and the impact on long term outcomes. We evaluate the impact of baseline use of OMT versus Non-OMT on long-term clinical outcomes in pts receiving CABG compared to patients with medical treatment alone (MED). METHODS: The STICH trial randomized 1212 pts with CAD and left ventricular ejection fraction (LVEF) ≤ 35% to CABG + MED versus MED alone. OMT was defined as a combination of 4 drugs ACEI/ARB, BB, statin, and at least one antiplatelet drug at baseline, with a median follow up over 9.8 years. RESULTS: At baseline, 58.7% of the pts were on OMT (CABG 56.1%; MED 61.5%), remaining stable or increasing similarly for both groups during follow up, for example, at 1 year, CABG 73.2% and Med 74.3%. Age, gender, diabetes were similar. OMT pts had less atrial fibrillation, lower angina score class, less advance heart failure class and better renal function. There were no differences in LVEF and end systolic and diastolic volume index. OMT use at baseline was associated with a significantly lower all-cause mortality compared to Non- OMT pts (58.8% vs 67.6%, log-rank P<0.001), lower cardiovascular mortality (40.3% vs 51.4%, log-rank P<0.001) and lower HF death, 11.2% vs 15.6%, log-rank P<0.001). Sudden death was not different (21.5% vs 23.4%, P=0.058). In a multivariable Cox model, OMT was associated with a lower All-cause mortality (HR 0.78, 95%CI 0.66-0.91 P=0.001). The effect of OMT was similar for both CABG and MED only pts for these outcomes (p=0.189 for interaction). Hospitalization for HF was not reduced with OMT. CONCLUSION: OMT is associated with lower all-cause mortality in CABG eligible HF pts, regardless of the lower baseline risk among OMT pts and the performance of CABG. OMT should be strongly considered for all pts with ischemic cardiomyopathy regardless of whether CABG is performed. (AU)