1/ REVIVED BCIS2 vs. STICH.
In STICH(es), CABG had a mortality benefit over MT. No such benefit of PCI vs. MT in REVIVED BCIS2. Does that mean CABG is superior to PCI in ischemic cardiomyopathy?@GreggWStone @JWMoses @SVRaoMD @ShariqShamimMD @evandrofilhobr @djc795 @ajaykirtane
In STICH(es), CABG had a mortality benefit over MT. No such benefit of PCI vs. MT in REVIVED BCIS2. Does that mean CABG is superior to PCI in ischemic cardiomyopathy?@GreggWStone @JWMoses @SVRaoMD @ShariqShamimMD @evandrofilhobr @djc795 @ajaykirtane
2/ STICH enrolled 1212 patients to be powered for death. REVIVED with 58% smaller sample size (700 patients) woefully underpowered for mortality. @mmamas1973 @rallamee @DLBHATTMD @DFCapodanno @CMichaelGibson @HadyLichaaMD @AntoniousAttall
3/ Indirect comparison of CABG vs. PCI from these 2 trials are only valid if the comparator (MT) is same or similar between the two trials (principle of transitivity). Is the MT arm in STICH comparable to that of REVIVED?
4/ Med therapy in STICH was largely BB and ACE/ARB. REVIVED used BB, ACE/ARB, 57% were on MRA, 37% on ARNI. In addition, ICD use was 18.6% in STICH vs. 54% (cardiac device) in REVIVED. Med therapy significantly better (but not to current day standards) than STICH.
5/ Consequently, 4-year death rate with Med lower in REVIVED (~26%) than in STICH (~32%) (Rates extrapolated from CIF plots).
6/ Interestingly, 4-year death with PCI in REVIVED and CABG in STICH are largely similar (~28%) (Extrapolated from CIF plots). The dif in outcome bn the 2 trials, in part, is due to difference in event rates in the MT arm of the trials (REVIVED (~26%) than in STICH (~32%)).
7/ Finally, EF did not improve significantly with PCI when compared with MT in REVIVED. This is similar to the results from STICH where EF improvement >=10% was in 19% in the CABG group and 16% in the MT group (P=0.30).
8/ My take on REVIVED BCIS is the following:
- It is a win for medical therapy, which admittedly was far from optimal when compared with today's standards. Will PCI or even CABG have a mortality benefit over today's standard of medical therapy?
- It is a win for medical therapy, which admittedly was far from optimal when compared with today's standards. Will PCI or even CABG have a mortality benefit over today's standard of medical therapy?
9/ - Both STICH and REVIVED BCIS show that EF improvement is only seen in the minority with revasc
- Relative merits of PCI vs. CABG can only be compared via a head to head randomized trial
- Relative merits of PCI vs. CABG can only be compared via a head to head randomized trial
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