In patients with stable coronary artery disease and moderate-to-severe ischaemia, initial invasive strategy did not reduce cardiovascular mortality or myocardial infarction compared to optimized medic
Does an initial invasive strategy reduce cardiovascular mortality or myocardial infarction compared with optimised medical therapy in patients with stable coronary artery disease and chronic total coronary occlusions?
While the ISCHEMIA trial showed no hard clinical benefit for an invasive strategy in stable CAD, its applicability to CTOs is limited, highlighting the need for individualized decision-making based on symptoms, ischemia, viability, and Heart Team discussion.
Abstract The management of chronic total coronary occlusions (CTOs) remains one of the most debated areas in interventional cardiology because of its technical complexity and the relatively high risk of procedural complications. Although the effectiveness of percutaneous coronary intervention for CTOs (CTO-PCI) in improving symptoms has been demonstrated, its impact on hard clinical outcomes remains controversial. The International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA Trial) and the ISCHEMIA CTO sub-study provide important insights: in patients with stable coronary artery disease and moderate-to-severe ischaemia, an initial invasive strategy does not reduce cardiovascular mortality or myocardial infarction compared with optimised medical therapy. However, the trial was not designed to specifically assess the effectiveness of CTO-PCI, and only a minority of enrolled patients had a CTO, which was revascularised in only few cases. In addition, the ISCHEMIA trial excluded high-risk patients who are frequently encountered in everyday clinical practice, such as those with left main coronary artery disease, severe symptoms, or recent acute coronary syndromes. This article critically analyses the results of the ISCHEMIA Trial in the context of CTOs, comparing them with evidence from dedicated CTO-PCI studies, and proposes an integrated decision-making model based on symptom control, objective demonstration of inducible ischaemia and myocardial viability, multimodal imaging, and discussion within the Heart Team.
Madaudo et al. (2026) studied this question. In patients with stable coronary artery disease and moderate-to-severe ischaemia, initial invasive strategy did not reduce cardiovascular mortality or myocardial infarction compared to optimized medic.