Sudden Cardiac Death in Patients with Ischemic Heart Failure Undergoing CABG: Results from the STICH trial

Introduction: Current guidelines do not support use of implantable cardioverter defibrillators (ICD) within 3 months of coronary artery bypass grafting (CABG) surgery as such patients were excluded from primary prevention trials. Since protection from sudden cardiac death (SCD) with CABG may not be immediately achieved, our aim is to examine the timing and key predictors of SCD after CABG. Methods: Patients enrolled in the STICH Trial who underwent CABG with or without surgical ventricular reconstruction (SVR) formed the population. We excluded patients with ICDs in-situ and those randomized to medical therapy only. The primary outcome was SCD adjudicated by a blinded committee. Core laboratories measured left ventricular ejection fraction (EF) and end systolic volume index (ESVI). The Fine-Gray model was used to examine factors associated with SCD and to estimate cumulative incidence. Results: Of 1411 patients who received CABG without (n = 934) or with SVR (n = 477) eligible for this analysis, 113 and 311 patients died from SCD and other causes, respectively, over a median follow-up of 46 months. Patients who had SCD were similar to patients who did not die in that they were younger and had less comorbid conditions than those who died of other causes. The mean EF was lower and ESVI was higher in all patients who died compared to those who lived. ESVI was the strongest predictor of SCD in both univariate and multivariable models. In the first 30 days after CABG, SCD was relatively infrequent (n=5, 7% of deaths), however the proportion increased to 32% (n=12) of deaths after 30 days and remained stable thereafter (Figure). Conclusion: SCD is infrequent relative to death from other causes among patients with ischemic heart failure after CABG particularly during the initial 30 days. The proportion of SCD increases and remains stable 30 days after surgery. Risk stratification for SCD may need to begin earlier than current guidelines recommend and extend beyond the EF to include ESVI. ![][1] [1]: /embed/graphic-1.gif