The heart failure challenge: optimizing medical and surgical management.

The treatment of patients with coronary artery disease and left ventricular dysfunction has improved markedly over the past two decades. Nevertheless, the morbidity and mortality rates remain high in this population. In addition to pharmacological therapies to attenuate neurohumoral overactivation, the present challenge is to find additional therapeutic avenues. Percutaneous coronary intervention, although widely used in patients with coronary artery disease, is more challenging with multivessel disease and associated left ventricular dysfunction, and its optimal use in heart failure remains in question. Cardiac surgical revascularization and surgical ventricular restoration have also been advocated. To date, there are no prospective, randomized clinical studies to prove a benefit from these invasive interventions and to identify which patients may derive the most benefit compared with optimal medical therapy alone. The current management of patients with ischemic heart failure needs to be challenged and requires an objective evaluation of these invasive interventions. The ongoing Surgical Treatment for Ischemic Heart Failure (STICH) trial is the first randomized trial designed to determine the long-term benefits of surgical revascularization and surgical ventricular restoration compared with optimal medical therapy alone. The results of this study will provide additional evidence-based information to guide physicians in the rational allocation of health care resources. The role of percutaneous angioplasty in patients with ischemic heart failure also needs to be addressed objectively.