Coronary Bypass Grafts Compared to Non-Invasive Medical Therapy

An article in JAMA looked at the response of cardiologists to a recent study showing that medical therapy produced the same degree of protection against death as coronary artery bypass grafts (CABGs). The physicians were remarkably resistant to implementing the results of the study.

Excerpt:

"A trial of 2 treatment strategies for heart failure, one much more expensive and invasive, found that both provide the same degree of protection against death within about 5 years after initiating treatment. Such a finding suggests that cardiologists will opt for the cheaper and less invasive therapy, but that may not be the case.

At issue is treatment of patients with coronary artery disease and left ventricular dysfunction. At the American College of Cardiology scientific session here in April, researchers compared the efficacy and safety of coronary artery bypass graft (CABG) surgery plus optimal medical therapy with medical therapy alone. The Surgical Treatment for Ischemic Heart Failure (STICH) trial included 1212 patients with left ventricular ejection fraction of 35% or less and coronary artery disease amenable to CABG, who were randomized to either treatment strategy. After a median follow-up of 56 months, 218 of 610 patients randomized to CABG plus medical therapy died compared with 244 of 602 patients randomized to medical therapy alone; CABG plus medical therapy reduced death rates by 14% compared with medical therapy alone, but the difference did not reach statistical significance (Velazquez EJ et al. N Engl J Med. 2011;364[17]:1607-1616).

Those arguing that CABG should remain a viable treatment option for these patients point to secondary analyses showing that those who had the surgery had lower rates of hospitalization for cardiovascular causes or death. Robert O. Bonow, MD, a STICH coinvestigator and a professor of medicine at Northwestern University's Feinberg School of Medicine in Chicago, pointed out that this is the first prospective randomized study of these types of patients and treatment options and that it will take time to analyze the findings to identify patients who will truly benefit more from one treatment option than the other.

'There was a reduction in mortality with CABG, but it was not significant,” Bonow said. “But the secondary end points are intriguing. There is also a difference between a clinical trial and the way you interpret the result and the relevance it has in the clinical setting.'

But in an age of emerging clinical effectiveness research in which studies pit different treatment strategies against each other to find the best options, the fact that cardiologists are still arguing for CABG and offering it to patients in a shared decision-making environment baffles Harlan M. Krumholz, MD, professor of medicine at Yale University School of Medicine in New Haven, Conn. “When you are talking about open-heart surgery and the discomfort and risk and cost, shouldn't it have to be a superior strategy in order for us to have any enthusiasm to recommend it to our patients?” Krumholz asked. “And the idea that the patient has an equal choice seems to be putting the brightest possible light on truly a negative study.”