Simon Thackray

Imperial College London, Londinium, England, United Kingdom

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Publications (59)275.96 Total impact

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    ABSTRACT: sec> Introduction An association between improved survival and successful PCI of chronic total coronary occlusions (CTO) when compared with failed PCI has been widely reported. However a comparison between elective medical therapy and CTO PCI is more relevant to clinical decision making. We compared long-term clinical outcomes in a cohort of patients with an identified CTO on angiography between these two treatment groups, hypothesising there would be a difference in all-cause mortality at 5 year follow-up. Methods Patients found to have a CTO on angiography between 2002 and 2008, without prior CABG or important structural heart disease in a single tertiary centre were identified using a dedicated database. Patients undergoing CTO PCI and elective medical therapy to the CTO were matched using a propensity score to adjust for baseline clinical and angiographic differences. Events at follow-up were identified using national death certification records and national registries for myocardial infarction, CABG and PCI. Results In total 1957 patients were identified, a CTO was treated by PCI in 405 (20.7%) and medical therapy in 667 (34.1%), 885 (45.2%) patients underwent CABG. Of those treated by PCI or medical therapy, propensity score matching identified 389 pairs of patients. PCI was successful in 238 patients (61.2%). There was no difference in the primary study objective of 5 year mortality between the propensity matched treatment groups (CTO PCI: 10.8%, medical therapy: 15.7%; HR 0.74; 95% CI 0.49 to 1.11; p = 0.146), or after adjustment for Syntax score: (HR 0.81; 95% CI 0.53–1.25; p = 0.336). There remained no difference if only the 238 matched pairs in which CTO PCI was successful were included (HR 0.83; 95% CI 0.48 to 1.42; p = 0.493). There was an increase in repeat revascularisation associated with CTO PCI (HR 2.18; 95% CI 1.49–3.18; p < 0.001). This difference was not present in the successful PCI matched pair subgroup (HR 0.79; 95% CI 0.45–1.37; p = 0.397). Conclusions Using an alternative approach to much of the existing literature, we have not demonstrated an associated difference in survival between patients with a CTO treated by PCI versus those in whom the CTO was treated medically. Doubt remains as to whether PCI of a CTO should be performed on grounds of prognosis. Abstract 107 Figure 1 Kaplan-Meier curve showing comparison of 5 year survival between propensity matched groups of patients with an identified CTO treated by elective medical therapy vs. CTO PCI </sec
    Heart (British Cardiac Society) 06/2015; 101(Suppl 4):A61-A62. DOI:10.1136/heartjnl-2015-308066.107 · 6.02 Impact Factor
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    ABSTRACT: To describe the UK experience with Renal Denervation (RDN). RDN may lower blood pressure (BP) in people with resistant hypertension.The UK Renal Denervation Affiliation is an independent, investigator-led initiative. Each centre had done >5 cases. A standardised dataset was collected retrospectively, anonymised and submitted to the coordinating centre for analysis. Results from 246 cases from 16 centres are reported. Average cases per centre was 15. Five different ablation technologies were used: unipolar catheters in 198 and multipolar in 48.Mean age was 56.7 years, 53% female, 87% Caucasian and 27% diabetes. Previous stroke/TIA - 24%; myocardial infarction - 15%; proteinuria - 26%.Patients were screened by a mean of 1.6 specialists with an interest in hypertension. 86% attended specialist hypertension clinics.On average 4.7 drugs were used before RDN; 95% were on 3+ drugs; 90% were on RAS blockers, 90% diuretics and 56% aldosterone antagonists at time of RDN.Pre-RDN mean office BP was 186/102 mmHg. Ambulatory blood pressure monitoring (ABP) data were available for 179 patients (73%). Average pre-RDN ABP was: daytime - 170/98; night - 154/86.Average follow-up was 10.7 months. Mean Office BP post-RDN was 164/93, a fall of 22/9 mmHg (P < 0.001). In 24%, office SBP fell 40+ mmHg. On average, 0.8 drugs were withdrawn per patient and 0.3 drugs added between RDN and follow-up.Mean daytime ABP after RDN was 158/92 and nighttime ABP 145/81 - fall in daytime ABP was 12/6 (p < 0.001). 18% had a drop in day systolic ABP of >20 mmHg. A decrease in GFR >25% was seen at 10 months in 5% patients. Otherwise, no significant complications were seen. In a cohort of 246 patients from 16 UK centres who had undergone renal denervation, a significant fall in blood pressure was observed. Office BP fell by 22/9 mmHg. Daytime ambulatory BP fell by 12/6 mmHg.Carefully selected patients with resistant hypertension exhibited significant BP reduction following RDN. This was a group with severe hypertension who had been well characterised in specialist hypertension clinics. Drug additions/withdrawals did not appear to explain the BP fall.
    Journal of Hypertension 06/2015; 33 Suppl 1 - ESH 2015 Abstract Book:e109. DOI:10.1097/01.hjh.0000467643.85364.79 · 4.22 Impact Factor
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    ABSTRACT: The presence of a concomitant chronic total coronary occlusion (CTO) and a large collateral contribution might alter the fractional flow reserve (FFR) of an interrogated vessel, rendering the FFR unreliable at predicting ischemia should the CTO vessel be revascularized and potentially affecting the decision on optimal revascularization strategy. We tested the hypothesis that donor vessel FFR would significantly change after percutaneous coronary intervention of a concomitant CTO. In consecutive patients undergoing percutaneous coronary intervention of a CTO, coronary pressure and flow velocity were measured at baseline and hyperemia in proximal and distal segments of both nontarget vessels, before and after percutaneous coronary intervention. Hemodynamics including FFR, absolute coronary flow, and the coronary flow velocity-pressure gradient relation were calculated. After successful percutaneous coronary intervention in 34 of 46 patients, FFR in the predominant donor vessel increased from 0.782 to 0.810 (difference, 0.028 [0.012 to 0.044]; P=0.001). Mean decrease in baseline donor vessel absolute flow adjusted for rate pressure product: 177.5 to 139.9 mL/min (difference -37.6 [-62.6 to -12.6]; P=0.005), mean decrease in hyperemic flow: 306.5 to 272.9 mL/min (difference, -33.5 [-58.7 to -8.3]; P=0.011). Change in predominant donor vessel FFR correlated with angiographic (%) diameter stenosis severity (r=0.44; P=0.009) and was strongly related to stenosis severity measured by the coronary flow velocity-pressure gradient relation (r=0.69; P<0.001). Recanalization of a CTO results in a modest increase in the FFR of the predominant collateral donor vessel associated with a reduction in coronary flow. A larger increase in FFR is associated with greater coronary stenosis severity. © 2015 American Heart Association, Inc.
    Circulation Cardiovascular Interventions 04/2015; 8(4). DOI:10.1161/CIRCINTERVENTIONS.114.002219 · 6.98 Impact Factor
  • Journal of the American College of Cardiology 09/2014; 64(11):B89. DOI:10.1016/j.jacc.2014.07.356 · 15.34 Impact Factor
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    ABSTRACT: Fractional flow reserve (FFR) guided angioplasty has been shown to have a beneficial effect on clinical outcome in patients with multi-vessel coronary disease. However, multi-vessel disease is frequently accompanied by a chronic total occlusion (CTO). We have limited understanding of the effect of the donation of a collateral supply to collateral dependent myocardium on the FFR. Marked changes in non-target vessel FFR post recanalisation of CTOs have been reported, but the consistency of this phenomenon remains uncertain and changes in haemodynamic indices immediately post-angioplasty might be confounded by the effect of the vessel trauma of angioplasty on the microvasculature. If the phenomenon is consistent, we might expect haemodynamics in a vessel donating collaterals to a CTO to be dependent on the extent of angiographic collateral flow originating from it.
    Heart (British Cardiac Society) 06/2014; 100(Suppl 3):A42. DOI:10.1136/heartjnl-2014-306118.72 · 6.02 Impact Factor
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    ABSTRACT: Aims: Marked changes in non-target vessel FFR post recanalisation of chronic total coronary occlusions have been reported, but the consistency of the phenomenon remains uncertain, if a large change in FFR were universal we might expect an association between non-target vessel haemodynamics and extent of collateral donation of the non-target vessels. We sought to compare microvascular resistance and coronary flow between each non-target vessel prior to PCI of a chronic total coronary occlusion. Methods and results: Prior to angioplasty of a chronic total coronary occlusion in 22 patients, simultaneous pressure and flow were measured at rest and during hyperaemia in the distal and proximal segment of each non-target vessel. Absolute coronary flow, coronary flow reserve, hyperaemic microvascular resistance and fractional flow reserve were calculated. Blinded to haemodynamic measurements, the predominant (or major) collateral donor vessel was selected and each vessel was graded by the size of the largest collateral branch which originated from it by collateral connection (CC) grade (0=no continuous connection, 1=threadlike connection, 2=side branch like connection). Haemodynamic measurements were compared between the major and minor collateral donor vessels. Continuous data is expressed as mean (standard deviation), mean differences are expressed as mean (confidence interval of the difference). Comparisons between groups were made using a paired t-test. All patients had right dominant coronary anatomy. The target vessel was the left anterior descending artery in 9 patients, circumflex artery in 2 and right coronary artery in 11. All target vessels were filled by a modified Rentrop grade of >2 (2 n=12, 3 n=10). Collateral connection grade for the major and minor collateral donor vessel were as follows: major: 2=11, 1=11, 0=0; minor 2=3, 1=8, 0=11. The Mean Duke Jeopardy Scores for the entirety of each non-target vessel were not significantly different between groups (major=3.27 (1.91), minor=4.09 (1.44)). Mean diameter stenosis and fractional flow reserve did not differ significantly between groups. There was no significant difference in any of the measured haemodynamic indices between groups: hyperaemic microvascular resistance (mmHg/cm/s): major=2.01 (0.95), minor=2.19 (0.87), mean difference -0.18 (-0.74-0.38, p=0.51); hyperaemic absolute flow (ml/min): major=168.8 (97.7), minor=189.4 (126.9), mean difference 20.6(-30.7-72.0, p=.41); resting absolute flow adjusted for rate pressure product: major=105.8 (61.3) minor=111.6 (58.7), mean difference (-21.0-32.6, p=0.66); coronary flow reserve: major=2.11(0.61), minor=2.13 (0.78), mean difference -0.03(-0.36-0.42, p=0.88). Conclusions: The mechanism for a large rise in non-target vessel FFR post CTO angioplasty must involve a fall in coronary flow, and therefore resistance to flow, across a coronary stenosis. These results would suggest that the expected change in haemodynamics as a result of recanalisation of a chronic total occlusion are likely to be relatively small. The relationship between pressure gradient and flow of a coronary stenosis may be the major determinant of the size in change in FFR.
    EuroPCR; 05/2014
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    ABSTRACT: Aims: Whilst it seems clear that the endothelium distal to a chronic total coronary occlusion is dysfunctional in the immediate aftermath of PCI, it is not clear whether microvascular resistance and function is restored immediately, or whether this is also impaired. We sought to investigate microvascular resistance at rest and hyperaemia prior to and shortly after PCI of a chronic total coronary occlusion. Methods and results: In 10 patients undergoing PCI to a chronic total coronary occlusion, simultaneous pressure and flow velocity were measured using a Volcano ComboWire distal to the point of occlusion pre and post recanalisation. Post-recanalisation measures were compared with an unobstructed reference vessel subtending viable myocardium in the same patient. Hyperaemic microvascular resistance and coronary flow reserve as well as resting and hyperaemic instantaneous minimal microvascular resistance during the ‘wave free period’ were compared. Continuous values are expressed as mean (standard deviation) or median (interquartile range) and comparisons made with a paired t-test or Wilcoxon signed rank sum test, depending on conformity to a Gaussian distribution. Pre-PCI microvascular resistance was assessed in the target (chronically occluded) vessel in 9/10 patients. There was a significant redunction in hyperaemic microvascular resistance after PCI: pre PCI median 5.26(3.50-5.51) mmHg/cm/s, post-PCI median 1.51(1.25-3.44) mmHg/cm/s, p=0.028. We did not detect a significant difference in the reference vessel: pre-PCI median 2.15 (1.53-2.63), post-PCI median 1.72(1.34-2.02) p=0.31. There was no significant difference between reference and target vessels in hyperaemic microvascular resistance post-PCI, hyperaemic microvascular resistance was within the normal physiological range of <2 mmHg/cm/s in 7/10 target vessels (median 1.42(0.98-3.44) mmHg/cm/s) and 9/10 reference vessels (median 1.81(1.40-2.60) mmHg/cm/s), p=0.65. Similarly, there was no difference in coronary flow reserve (target vessel mean 1.96(0.70), reference vessel 2.22(0.98), p=0.57. Minimal instantaneous microvascular resistance measured during the ‘wave free period’ did not differ between target and reference vessels either at rest: target vessel median 2.31(1.45-2.90) mmHg/cm/s, reference vessel median 3.75(1.89-4.32) mmHg/cm/s, p=0.28; or hyperaemia: target vessel median 0.90(0.56-1.80) mmHg/cm/s, reference vessel median 1.05(0.87-1.30), p=0.96. Conclusions: This small study suggests that target vessel microvascular resistance decreases rapidly after PCI of chronic total coronary occlusions and the vascodilatory capacity of the microcirculation in response to Adenosine rapidly returns to normal in a high proportion of cases. Although physiological lesion assessment for clinical decision making in this setting is limited by endothelial dysfunction in the epicardial vessel, and is probably best avoided; these results have implications for the interpretation of clinical studies, and support the validity of those that have measured recruitable collateral function after PCI of chronic total coronary occlusions.
    EUROPCR 2014; 05/2014
  • Journal of the American Society of Hypertension 04/2014; 8(4):e103-e104. DOI:10.1016/j.jash.2014.03.239 · 2.68 Impact Factor
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    Circulation Cardiovascular Interventions 04/2013; 6(2):184-197. DOI:10.1161/CIRCINTERVENTIONS.112.000037 · 6.98 Impact Factor
  • Chelliah RK · Bourantas C · Thackray SD
    01/2012; 03(04). DOI:10.4172/2155-9880.1000185
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    Verah Harper · Simon D Thackray · Andrew L Clark
    International journal of cardiology 12/2011; 153(2):236-7. DOI:10.1016/j.ijcard.2011.09.045 · 6.18 Impact Factor
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    ABSTRACT: Aortic atherosclerosis reduces compliance in the systemic circulation and increases peripheral resistance, afterload and left ventricular wall stress. In patients with heart failure, these changes can impair left ventricular systolic function and energy efficiency, which could reduce exercise capacity. Though the interaction and the impact of aortic atherosclerosis on left ventricular function have been investigated, its prognostic implications in patients with heart failure are unclear. We used cardiac magnetic resonance imaging and gadolinium-enhanced abdominal aortography to investigate the prevalence and prognostic impact of atherosclerotic disease of the abdominal aorta and its side branches in 355 patients with heart failure. Sclerotic abdominal aortic disease was defined as a luminal narrowing >50% of the aorta and its side branches or the presence of abdominal aortic aneurysm. Patients with disease of the aorta and its branches were older (P < 0.0001), had overall longer stay in hospital (P = 0.006) and had more admissions (P = 0.001) and worse prognosis (hazard ratio: 1.97, 95% confidence interval: 1.29-3.00, P = 0.002) than those without. In a multivariable model, increasing age and pulse pressure, diabetes mellitus and increasing left ventricular end-diastolic volume were associated with a worse prognosis, but sclerotic abdominal aortic disease was not independently related to outcome (hazard ratio: 1.06; 95% confidence interval: 0.64-1.74; P = 0.823). These data demonstrate that atherosclerosis of the abdominal aorta and its side branches is common and associated with increased morbidity in patients with chronic heart failure. How such disease should be managed remains uncertain, but its recognition and characterisation are the first steps in finding out.
    Heart Failure Reviews 10/2011; 17(2):229-39. DOI:10.1007/s10741-011-9284-9 · 3.99 Impact Factor
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    ABSTRACT: IntroductionChronic total occlusion (CTO) of coronary vessels is a relatively common finding on diagnostic angiography. There has been increasing interest in this clinically important area with development of technologies resulting in improved recanalisation rates. However, long term survival data in this cohort is lacking. In this study we looked at survival of patients in whom complete, successful revascularisation was achieved.Methods We identified consecutive patients, found to have CTO of at least one vessel of more than 1-month duration, on angiography performed between January 1999 and August 2000 in a single tertiary centre. We used a dedicated database to record data on variables and used central National Health Service database to obtain survival data. Results were analysed using SPSS statistics version 17.ResultsWe included 331 patients in the analysis. Mean age was 56.8 ±19.8 years, 76.1% were male and 21.8% (n=71) were diabetic. Mean duration of CTO was 29.5±25.9 months and was only reliably estimated in 82.5% of cases. Median follow-up duration was 10.09±3.3 years. Complete revascularisation was successfully achieved in 53.5% (n=177) patients, while 46.5% (n=154) were either treated medically from the outset or had failed or incomplete revascularisation. Both groups were age matched. Overall 10-year survival was 66.5%; those with complete revascularisation had significantly improved survival over those with incomplete revascularisation or medical therapy (75.1% vs 56.5%, p
    Heart (British Cardiac Society) 06/2011; 97(1). DOI:10.1136/heartjnl-2011-300198.32 · 6.02 Impact Factor
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    ABSTRACT: BACKGROUND: The assessment 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: 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), dobutamine echocardiography, or both to assess myocardial viability on the basis of prespecified thresholds. RESULTS: Among the 1212 patients enrolled in the randomized trial, 601 underwent assessment of myocardial 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). CONCLUSIONS: The presence 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.).
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    ABSTRACT: BACKGROUND: The assessment 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: 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), dobutamine echocardiography, or both to assess myocardial viability on the basis of prespecified thresholds. RESULTS: Among the 1212 patients enrolled in the randomized trial, 601 underwent assessment of myocardial 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). CONCLUSIONS: The presence 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.).
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    ABSTRACT: BACKGROUND: The assessment 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: 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), dobutamine echocardiography, or both to assess myocardial viability on the basis of prespecified thresholds. RESULTS: Among the 1212 patients enrolled in the randomized trial, 601 underwent assessment of myocardial 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). CONCLUSIONS: The presence 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.).
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    ABSTRACT: BACKGROUND: The role of coronary-artery bypass grafting (CABG) in the treatment of patients with coronary artery disease and heart failure has not been clearly established. METHODS: Between July 2002 and May 2007, a total of 1212 patients with an ejection fraction of 35% or less and coronary artery disease amenable to CABG were randomly assigned to medical therapy alone (602 patients) or medical therapy plus CABG (610 patients). The primary outcome was the rate of death from any cause. Major secondary outcomes included the rates of death from cardiovascular causes and of death from any cause or hospitalization for cardiovascular causes. RESULTS: The primary outcome occurred in 244 patients (41%) in the medical-therapy group and 218 (36%) in the CABG group (hazard ratio with CABG, 0.86; 95% confidence interval [CI], 0.72 to 1.04; P=0.12). A total of 201 patients (33%) in the medical-therapy group and 168 (28%) in the CABG group died from an adjudicated cardiovascular cause (hazard ratio with CABG, 0.81; 95% CI, 0.66 to 1.00; P=0.05). Death from any cause or hospitalization for cardiovascular causes occurred in 411 patients (68%) in the medical-therapy group and 351 (58%) in the CABG group (hazard ratio with CABG, 0.74; 95% CI, 0.64 to 0.85; P<0.001). By the end of the follow-up period (median, 56 months), 100 patients in the medical-therapy group (17%) underwent CABG, and 555 patients in the CABG group (91%) underwent CABG. CONCLUSIONS: In this randomized trial, there was no significant difference between medical therapy alone and medical therapy plus CABG with respect to the primary end point of death from any cause. Patients assigned to CABG, as compared with those assigned to medical therapy alone, had lower rates of death from cardiovascular causes and of death from any cause or hospitalization for cardiovascular causes. (Funded by the National Heart, Lung, and Blood Institute and Abbott Laboratories; STICH ClinicalTrials.gov number, NCT00023595.).
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    ABSTRACT: BACKGROUND: The assessment 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: 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), dobutamine echocardiography, or both to assess myocardial viability on the basis of prespecified thresholds. RESULTS: Among the 1212 patients enrolled in the randomized trial, 601 underwent assessment of myocardial 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). CONCLUSIONS: The presence 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.).
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    [Show abstract] [Hide abstract]
    ABSTRACT: BACKGROUND: The assessment 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: 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), dobutamine echocardiography, or both to assess myocardial viability on the basis of prespecified thresholds. RESULTS: Among the 1212 patients enrolled in the randomized trial, 601 underwent assessment of myocardial 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). CONCLUSIONS: The presence 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.).
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: BACKGROUND: The role of coronary-artery bypass grafting (CABG) in the treatment of patients with coronary artery disease and heart failure has not been clearly established. METHODS: Between July 2002 and May 2007, a total of 1212 patients with an ejection fraction of 35% or less and coronary artery disease amenable to CABG were randomly assigned to medical therapy alone (602 patients) or medical therapy plus CABG (610 patients). The primary outcome was the rate of death from any cause. Major secondary outcomes included the rates of death from cardiovascular causes and of death from any cause or hospitalization for cardiovascular causes. RESULTS: The primary outcome occurred in 244 patients (41%) in the medical-therapy group and 218 (36%) in the CABG group (hazard ratio with CABG, 0.86; 95% confidence interval [CI], 0.72 to 1.04; P=0.12). A total of 201 patients (33%) in the medical-therapy group and 168 (28%) in the CABG group died from an adjudicated cardiovascular cause (hazard ratio with CABG, 0.81; 95% CI, 0.66 to 1.00; P=0.05). Death from any cause or hospitalization for cardiovascular causes occurred in 411 patients (68%) in the medical-therapy group and 351 (58%) in the CABG group (hazard ratio with CABG, 0.74; 95% CI, 0.64 to 0.85; P<0.001). By the end of the follow-up period (median, 56 months), 100 patients in the medical-therapy group (17%) underwent CABG, and 555 patients in the CABG group (91%) underwent CABG. CONCLUSIONS: In this randomized trial, there was no significant difference between medical therapy alone and medical therapy plus CABG with respect to the primary end point of death from any cause. Patients assigned to CABG, as compared with those assigned to medical therapy alone, had lower rates of death from cardiovascular causes and of death from any cause or hospitalization for cardiovascular causes. (Funded by the National Heart, Lung, and Blood Institute and Abbott Laboratories; STICH ClinicalTrials.gov number, NCT00023595.).

Publication Stats

1k Citations
275.96 Total Impact Points

Institutions

  • 2015
    • Imperial College London
      Londinium, England, United Kingdom
  • 2000–2014
    • Hull and East Yorkshire Hospitals NHS Trust
      • Department of Cardiology
      Kingston upon Hull, England, United Kingdom
  • 2002–2013
    • University of Hull
      • Academic Cardiology
      Kingston upon Hull, England, United Kingdom
  • 2003
    • Kingston College United Kingdom
      Londinium, England, United Kingdom