Dr KK Answers: What to opt: Medical or surgical revascularization in patients with coronary heart blockages with reduced left ventricular function (heart pumping)?

Up to 50% of patients with low pumping function of the heart due to coronary heart blockages have a significant amount of viable hibernating heart muscles. Many earlier studies have shown that, when compared to drugs, surgical revascularization of hibernating heart muscles improves both survival and heart function. The Surgical Treatment for Ischemic Heart Failure (STICH) trial was the first randomized trial to compare the combination of optimal medical therapy and surgical revascularization with optimal medical therapy alone in patients with stable heart disease, heart pumping function 0f 35 percent or less, and coronary artery blockages amenable to coronary artery bypass graft (CABG) surgery.

Compared to optimal medical therapy alone, optimal medical therapy plus CABG surgery resulted in no significant improvement in all-cause mortality at a median follow-up of 56 months (36 versus 41 percent with medical therapy alone). 

In all patients with heart pumping function of 35 percent or less and coronary artery blockages amenable to CABG surgery, one should opt for an initial course of optimal medical therapy alone rather than optimal medical therapy plus CABG surgery. This is based on the significant morbidity associated with CABG surgery. 

However one should opt for CABG surgery in presence of ongoing anginal symptoms despite optimal medical therapy.
(N Engl J Med 2011; 364:1607)