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Heart Failure2011New England Journal of Medicine

STICH

Surgical Treatment for Ischemic Heart Failure

Sample Size
1,212
Study Design
Multicenter, international, randomized, open-label trial with extended follow-up (STICHES)
Year Published
2011
Category
Heart Failure

Clinical Question

Does CABG plus medical therapy reduce all-cause mortality compared with medical therapy alone in patients with coronary artery disease and left ventricular systolic dysfunction?

Population

Patients with coronary artery disease amenable to CABG and left ventricular ejection fraction ≤35% at 127 sites in 26 countries.

Intervention

CABG plus optimal medical therapy

Control

Optimal medical therapy alone

Primary Endpoint

All-cause mortality

Key Findings

1

At a median follow-up of 56 months, all-cause mortality was 36% with CABG vs 41% with medical therapy (HR 0.86; 95% CI, 0.72-1.04; p=0.12).

2

At 10-year follow-up (STICHES), all-cause mortality was 58.9% with CABG vs 66.1% with medical therapy (HR 0.84; 95% CI, 0.73-0.97; p=0.02).

3

Cardiovascular mortality at 10 years was significantly lower with CABG (40.5% vs 49.3%; HR 0.79; p=0.006).

4

Death from any cause or hospitalization for cardiovascular causes was lower with CABG at both 5 and 10 years.

5

Adding surgical ventricular reconstruction (SVR) to CABG did not improve outcomes beyond CABG alone (SVR Hypothesis).

Impact on Clinical Practice

STICH and its extended follow-up, STICHES, provided essential evidence about the role of surgical revascularization in ischemic heart failure. The initial 5-year results were statistically negative for the primary endpoint, creating uncertainty about CABG's value in this population. However, the landmark 10-year follow-up (STICHES) revealed a significant mortality benefit of CABG, with a 16% relative reduction in all-cause death and a 21% reduction in cardiovascular death. This demonstrated that the benefits of surgical revascularization in heart failure patients accrue over the long term and may not be apparent in shorter follow-up periods. STICH also definitively answered the question about surgical ventricular reconstruction: the SVR hypothesis showed no benefit of adding left ventricular reconstruction to CABG, effectively ending enthusiasm for this approach. The trial established that the survival benefit of CABG in ischemic heart failure comes from revascularization itself, not from ventricular remodeling surgery.

Guideline Impact

STICHES data contributed to the ACC/AHA Class IIa recommendation for CABG to improve survival in patients with ischemic cardiomyopathy, multivessel disease, and LVEF ≤35% who are suitable surgical candidates. ESC guidelines similarly recommend CABG for survival benefit in this population.

Limitations

High crossover rate from medical therapy to CABG (17%) diluted the intention-to-treat analysis, particularly at the original 5-year endpoint.

Enrolled predominantly male patients (88%), limiting generalizability to women with ischemic heart failure.

Viability testing was not required for enrollment, and the viability substudy showed no interaction between viability status and treatment benefit.

Reviewed by Serrie Lico, MD
Chief Medical Officer

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