This research is Trending!
March 30, 2020New England Journal of Medicine
Initial Invasive or Conservative Strategy for Stable Coronary Disease
Key result
Initial invasive strategy fails to reduce ischemic events or death versus a conservative strategy.
Why the study?
Does an initial invasive strategy reduce ischemic cardiovascular events or death from any cause in patients with stable coronary disease and moderate or severe ischemia?
Key Points
- To evaluate whether an invasive strategy reduces ischemic cardiovascular events or mortality compared to a conservative strategy in stable coronary disease.
- Compared two treatment strategies: invasive and conservative.
- Included patients with stable coronary disease and moderate or severe ischemia.
- Performed a median follow-up of 3.2 years.
- No significant reduction in ischemic events with the invasive strategy compared to conservative.
- Mortality rates were similar between both treatment strategies.
- Results varied based on how myocardial infarction was defined.
Structured PICO
Does an initial invasive strategy reduce ischemic cardiovascular events or death from any cause in patients with stable coronary disease and moderate or severe ischemia?
P
Population
Patients with stable coronary disease and moderate or severe ischemia
I
Intervention
Initial invasive strategy
C
Comparator
Initial conservative strategy
O
Outcome
Ischemic cardiovascular events or death from any cause over a median of 3.2 yearscomposite
In patients with stable coronary disease and moderate to severe ischemia, an initial invasive strategy does not significantly reduce the risk of ischemic cardiovascular events or death compared to a conservative strategy.
Limitations
- The trial findings were sensitive to the definition of myocardial infarction that was used.
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“The probability over 5.7 years that a patient's risk of dying is lower with the invasive strategy is nil, which means: Go with the patient's preference. Not undergoing revascularization is a reasonable strategy because there is no excess mortality.”
“Taken together, the quality of life and clinical results suggest that there is no need for invasive procedures in patients without symptoms. For those with angina, our results show it is just as safe to begin treating with medication and lifestyle change, and then if symptoms persist, discuss invasive treatment options.”
“These longer-term results build on our original findings, which is that patients with daily or even weekly angina will likely see improved quality of life, but we have more robust data that an invasive approach is not going to prolong life. Although cardiovascular mortality was reduced, with an invasive approach it was offset by higher non-cardiovascular mortality, so all-cause mortality is the same over time in both groups. Either strategy is acceptable, which is good news for patients, who have different preferences.”
Implication
Supports conservative management in stable CAD with moderate-severe ischemia; challenges prior consensus favoring routine invasive strategy.
Abstract
Among patients with stable coronary disease and moderate or severe ischemia, we did not find evidence that an initial invasive strategy, as compared with an initial conservative strategy, reduced the risk of ischemic cardiovascular events or death from any cause over a median of 3.2 years. The trial findings were sensitive to the definition of myocardial infarction that was used. (Funded by the National Heart, Lung, and Blood Institute and others; ISCHEMIA ClinicalTrials.gov number, NCT01471522.).
Discussion
No takes yet. Share an insight, caveat, or question.
Cite This Study
Maron et al. (2020) studied this question. An initial invasive strategy did not reduce the risk of ischemic cardiovascular events or all-cause death compared to a conservative strategy over 3.2 years.