An Age-Old Question
What Is Too Old for Coronary Artery Bypass Grafting in Heart Failure?
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- cardiovascular diseases
- coronary artery bypass
- heart failure
- thoracic surgery
- ventricular dysfunction, left
Article, see p 1314
The dilemma of how best to treat patients with severe coronary artery disease (CAD) and reduced left ventricular ejection fraction continues to perplex clinicians. One lone, but notable randomized trial, STICH (Surgical Treatment for Ischemic Heart Failure)1, and its 10-year follow-up report, STICHES (STICH Extension Study2), has helped clarify this clinical challenge. When a clinician is faced with clinical equipoise in a patient with a low ejection fraction and revascularizable CAD, coronary artery bypass grafting (CABG) in combination with optimal medical therapy (MED) provides an eventual reduction in cardiovascular mortality and hospitalizations, and an increase in overall survival, as long as an appreciable but not unanticipated early hazard of surgical mortality is accepted. Yet, it is important to understand that the conclusions are more nuanced than just presented. Despite this landmark study, the complexity of routine clinical practice poses several common quandaries that continue to be debated. Perhaps none is more difficult than what do with the older patient with heart failure and a reduced ejection fraction attributable to CAD.
In the current issue, Petrie and coinvestigators present a post hoc analysis from the STICHES report in which they ask the relevant clinical question of whether all age groups studied in the STICHES trial derived the same benefits of CABG added to MED in comparison with MED alone.3 For this analysis, the authors divided the STICHES cohort into age-based quartiles: Q1≤54 years, Q2>54 and ≤60 years, Q3>60 and ≤67 years, and Q4>67 years. When examining outcomes based on these quartiles, cardiovascular-related mortality was high and did not vary between the oldest and youngest quartiles in either randomized group. Consistent with the original report, CABG added to MED reduced cardiovascular mortality across all age quartiles in a statistically significant manner. Not surprisingly, they …