Medico

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n e w e ng l a n d j o u r na l

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original article

Myocardial Viability and Survival in Ischemic
Left Ventricular Dysfunction
Robert O. Bonow, M.D., Gerald Maurer, M.D., Kerry L. Lee, Ph.D.,
Thomas A. Holly, M.D., Philip F. Binkley, M.D., Patrice Desvigne-Nickens, M.D.,
Jaroslaw Drozdz, M.D., Ph.D., Pedro S. Farsky, M.D., Arthur M. Feldman, M.D.,
TorstenDoenst, M.D., Ph.D., Robert E. Michler, M.D., Daniel S. Berman, M.D.,
Jose C. Nicolau, M.D., Ph.D., Patricia A. Pellikka, M.D., Krzysztof Wrobel, M.D.,
Nasri Alotti, M.D., Ph.D., Federico M. Asch, M.D., Liliana E. Favaloro, M.D.,
Lilin She, Ph.D., Eric J. Velazquez, M.D., Robert H. Jones, M.D.,
and Julio A. Panza, M.D., for the STICH Trial Investigators*

A bs t r ac t
Background

Theassessment of myocardial viability has been used to identify patients with
coronary artery disease and left ventricular dysfunction in whom coronary-artery
bypass grafting (CABG) will provide a survival benefit. However, the efficacy of this
approach is uncertain.
Methods

The authors’ affiliations are listed in the
Appendix. Address reprint requests to
Dr. Bonow at the Center for CardiovascularInnovation, Northwestern University
Feinberg School of Medicine, 645 N. Michigan Ave., Suite 1006, Chicago, IL 60611, or
at r-bonow@northwestern.edu.

In a substudy of patients with coronary artery disease and left ventricular dysfunction who were enrolled in a randomized trial of medical therapy with or without
CABG, we used single-photon-emission computed tomography (SPECT), dobutamineechocardiography, or both to assess myocardial viability on the basis of prespecified thresholds.

* A list of the investigators in the Surgical
Treatment for Ischemic Heart Failure
(STICH) trial is provided in the Supplementary Appendix, available at NEJM.org.

Results

N Engl J Med 2011;364:1617-25.

Among the 1212 patients enrolled in the randomized trial, 601 underwent assessment ofmyocardial viability. Of these patients, we randomly assigned 298 to receive
medical therapy plus CABG and 303 to receive medical therapy alone. A total of 178
of 487 patients with viable myocardium (37%) and 58 of 114 patients without viable
myocardium (51%) died (hazard ratio for death among patients with viable myocardium, 0.64; 95% confidence interval [CI], 0.48 to 0.86; P = 0.003). However,after
adjustment for other baseline variables, this association with mortality was not
significant (P = 0.21). There was no significant interaction between viability status
and treatment assignment with respect to mortality (P = 0.53).

This article (10.1056/NEJMoa1100358) was
published on April 4, 2011, at NEJM.org.

Copyright © 2011 Massachusetts Medical Society.

Conclusions

Thepresence of viable myocardium was associated with a greater likelihood of
survival in patients with coronary artery disease and left ventricular dysfunction,
but this relationship was not significant after adjustment for other baseline variables. The assessment of myocardial viability did not identify patients with a differential survival benefit from CABG, as compared with medical therapy alone.(Funded by the National Heart, Lung, and Blood Institute; STICH ClinicalTrials.gov
number, NCT00023595.)
n engl j med 364;17

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april 28, 2011

The New England Journal of Medicine
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oronary artery disease is an important contributor to the rise in the prevalence of heart failure and in associated
mortality and morbidity.1-4 It has not been clearly established whether coronary-artery bypass
grafting (CABG) has a role in improving the
symptoms and the rate of survival of patients
with coronary artery disease and heart failure.
We conducted the...