2. Ischemic Cardiomyopathy
โThe most common cause of heart failure in
developed countries.โ
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
โImpairment of left ventricular function that
results from coronary artery diseaseโ
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
โContractile dysfunction in viable myocardium
that improves after revascularization or perhap
medical therapyโ
Chareonthaitawee P, Gersh BJ, Araoz PA, Gibbons RJ. J Am Coll Cardiol. 2005 Aug
16;46(4):567-74.
7. โNo randomized trials of revascularization in
patients with coronary artery disease with
decrease LVEFโ
โMultiple observational study suggesting
improvement in outcome with CABGโ
9. 1. Significant left main disease
2. Left main equivalent disease ( โฅ 70 % stenosis
of proximal LAD and Proximal LCX)
3. Proximal LAD stenosis with two or three
vessel disease
13. Study Design
โข Non-blinded, Randomized study.
โข Sponsored by NHLBI and Abbott Laboratories
โข Design to have 90% power to detect a 25%
reduction in mortality with CABG as compared
with medical therapy alone
15. Study Procedures
โข CABG is performed by cardiac surgeon in
whom have operative death rate less than 5%
โข Patients are followed at 30 days, every 4
months then every 6 months on next year
20. Study Population
โข 1212 Patients from 22 countries
โข 602 has medial therapy
โข 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 โs decision
4. Physicianโs decision
22. Follow-up
โข 5 of 1212 patients were loss to follow up.
โข 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
24.
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)
30. Limitations
โข Non blinded study has an effect on non fatal
outcome
โข Trial was design to detect 25% reduction in
mortality with CABG
โข Limited power and limited duration of follow-
up