Key result
Initial invasive strategy shows no all-cause mortality benefit over conservative management despite lower CV mortality.
Why the study?
Because an initial invasive strategy increased peri-procedural MI but decreased spontaneous MI over time in ISCHEMIA, the long-term effect on mortality remained to be determined.
Does an initial invasive management strategy reduce mortality in patients with chronic coronary disease and moderate-to-severe ischaemia compared to conservative management?
Observational
Does an initial invasive management strategy reduce mortality in patients with chronic coronary disease and moderate-to-severe ischaemia compared to conservative management?
In patients with chronic coronary disease and moderate-to-severe ischemia, an initial invasive strategy does not improve all-cause mortality at 5.7 years but is associated with lower CV mortality and higher non-CV mortality.
Does not favor routine invasive strategy for all-cause mortality in chronic coronary disease; leaves open CV/non-CV mortality trade-offs for prospective study.
The ISCHEMIA trial found no statistical difference in the primary endpoint between initial invasive and conservative management of patients with chronic coronary disease and moderate-to-severe ischaemia on stress testing. However, an invasive strategy increased peri-procedural myocardial infarction (MI) but decreased spontaneous MI with continued separation of curves over time. Thus, in order to assess the long-term effect of invasive management strategy on mortality, the ISCHEMIA-EXTEND observational study was planned including surviving participants from the initial phase of the ISCHEMIA trial with a projected median follow-up of nearly 10 years. Recently, an interim report of 7-year all-cause, cardiovascular (CV), and non-CV mortality rates has been published showing no difference in all-cause mortality between the two strategies, but with a lower risk of CV mortality and higher risk of non-CV mortality with an initial invasive strategy over a median follow-up of 5.7 years. The trade-offs in CV and non-CV mortality observed in ISCHEMIA-EXTEND raise many important questions regarding the heterogeneity of treatment effect, the drivers of mortality, and the relative importance and reliability of CV vs. all-cause mortality. Overall, findings from ISCHEMIA and ISCHEMIA-EXTEND trials might help physicians in shared decision-making as to whether to add invasive management to guideline-directed medical management in selected patients with chronic coronary artery disease and moderate or severe ischaemia.
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Bolognese et al. (2023) conducted an observational in Chronic coronary disease and moderate-to-severe ischaemia. Invasive management strategy vs. Conservative management was evaluated on All-cause mortality. An initial invasive strategy showed no difference in all-cause mortality compared to conservative management over a median 5.7 years, but had lower CV and higher non-CV mortality.
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