Key result
Revascularization in high-risk SIHD linked to ~38% lower death or MI versus conservative management.
Why the study?
The ISCHEMIA trial did not address the influence of left main disease and high-risk coronary anatomy on outcomes of an early invasive strategy in stable ischemic heart disease.
Does revascularization reduce the composite of all-cause death or MI in patients with stable ischemic heart disease and high-risk coronary anatomy compared to conservative management?
Cohort (n=9,016)
Does revascularization reduce the composite of all-cause death or MI in patients with stable ischemic heart disease and high-risk coronary anatomy compared to conservative management?
Effect estimate: IPW-HR 0.62 (95% CI 0.58-0.66)
p-value: p=<0.001
In patients with stable ischemic heart disease and high-risk coronary anatomy (left main or severe 3-vessel disease), revascularization is associated with significantly improved long-term survival and reduced risk of death or MI compared to conservative management.
May support revascularization consideration in high-risk anatomy; leaves open randomized confirmation of benefit.
Background The ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial failed to show a reduction in hard clinical end points with an early invasive strategy in stable ischemic heart disease (SIHD). However, the influence of left main disease and high‐risk coronary anatomy was left unaddressed. In a large angiographic disease‐based registry, we examined the modulating effect of revascularization on long‐term outcomes in anatomically high‐risk SIHD. Methods and Results 9016 patients with SIHD with high‐risk coronary anatomy (3 vessel disease with ≥70% stenosis in all 3 epicardial vessels or left main disease ≥50% stenosis [isolated or in combination with other disease]) were selected for study from April 1, 2002 to March 31, 2016. The primary composite of all‐cause death or myocardial infarction (MI) was compared between revascularization versus conservative management. A total of 5487 (61.0%) patients received revascularization with either coronary artery bypass graft surgery (n=3312) or percutaneous coronary intervention (n=2175), while 3529 (39.0%) patients were managed conservatively. Selection for coronary revascularization was associated with improved all‐cause death/MI as well as longer survival compared with selection for conservative management (Inverse Probability Weighted hazard ratio [IPW‐HR] 0.62; 95% CI 0.58 to 0.66; P <0.001; IPW‐HR 0.57; 95% CI 0.53–0.61; P <0.001, respectively). Similar risk reduction was noted with percutaneous coronary intervention (IPW‐HR 0.64, 95% CI 0.59–0.70, P <0.001) and coronary artery bypass graft surgery (IPW‐HR 0.61; 95% CI 0.57–0.66; P <0.001). Conclusions Revascularization in patients with SIHD with high‐risk coronary anatomy was associated with improved long‐term outcome compared with conservative therapy. As such, coronary anatomical profile should be considered when contemplating treatment for SIHD.
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Bainey et al. (2020) conducted a cohort in Stable ischemic heart disease with high-risk coronary anatomy (n=9,016). Revascularization (CABG or PCI) vs. Conservative management was evaluated on Composite of all-cause death or myocardial infarction (MI) (IPW-HR 0.62, 95% CI 0.58-0.66, p=<0.001). Revascularization in stable ischemic heart disease with high-risk anatomy reduced all-cause death or MI compared to conservative management (IPW-HR 0.62; 95% CI 0.58-0.66; P<0.001).
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