Blog entry by Meguid El Nahas
Another publication in a growing and confusing list of publications relating to the management of patients with IHD. The STICH trial investigator randomised 1212 patients with symptomatic CAD and EF <35% into medical therapy versus CABG. There was no signifcant difference in overrall survival (the primary endpoint). However, there was a lower rate of death from CV causes in those assigned to CABG (secondary end point). This paper is extremely well commented upon by James Fang (NEJM 2011;364:1671-2) who higlights the limitations of this trial including the doubtful significance of the difference in the secondary endpoints. The significance of differences in secondary endpoints is always questionable when the primary endpoint has not been met. Clearly, this study did not include patients with CKD (at least CKD3-5). Therefore, its relevance to the decision of the investigation and choice of treatment in asymptomatic patients for CAD remains uncertain in ESRD patients. Patients in the STICH trial had symptoms of angina. But, patients with ESRD who have significant LV systolic dysfunction should be investigated for CAD. Improved coronary circulation is one of the few interventions known to improve LV function. This is all the more relevant in those where renal transplantation is planned.