Key result
An initial invasive strategy did not significantly reduce the composite of major cardiovascular events compared to optimal medical therapy in patients with stable ischemic heart disease and moderate to severe ischemia (HR 0.93).
Why the study?
To summarize the ISCHEMIA trial and evaluate how its findings may impact cardiac imaging strategies for stable ischemic heart disease moving forward.
Does an initial invasive management strategy reduce major cardiovascular events compared to optimal medical therapy in stable patients with newly diagnosed moderate to severe myocardial ischemia?
Does an initial invasive management strategy reduce major cardiovascular events compared to optimal medical therapy in stable patients with newly diagnosed moderate to severe myocardial ischemia?
Hazard Ratio: 0.93 (95% CI 0.8–1.08)
Absolute Event Rate: 13.3% vs 15.5%
p-value: p=0.34
The ISCHEMIA trial challenges the dogma that moderate to severe ischemia mandates revascularization, emphasizing guideline-directed medical therapy and suggesting a greater role for CCTA and advanced imaging in stable ischemic heart disease.
Initial invasive strategy offers no clear event reduction; leaves open its role for symptoms or select high-risk subgroups.
PURPOSE OF REVIEW: This review is aimed at summarizing the recently published ISCHEMIA trial (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) and how its findings may impact cardiac imaging for stable ischemic heart disease (SIHD) moving forward. RECENT FINDINGS: The ISCHEMIA trial compared an initial invasive management strategy with goal of complete coronary revascularization versus an initial medical therapy strategy among stable patients with newly diagnosed moderate to severe myocardial ischemia on non-invasive testing. The trial results showed that an early invasive strategy did not reduce the incidence of major cardiovascular events over 3.2 years of follow-up as compared to optimal medical therapy in patients with SIHD. SUMMARY: The results of the landmark ISCHEMIA trial solidified the importance of guideline-directed medical therapy and have provided more evidence against the prevailing dogma that moderate to severe ischemia on traditional stress testing mandates coronary revascularization. This trial was not designed to compare different cardiac imaging and stress testing modalities for the assessment of coronary artery disease in patients undergoing their index evaluation for SIHD; however, its design, which included coronary computed tomographic angiography (CCTA) in most patients, and results have generated robust discussion regarding ways to improve non-invasive testing strategies in similar patient populations. We believe that increased utilization of CCTA to identify patients with and without high-risk SIHD, and advanced tests for ischemia, such as positron emission tomography and stress cardiac magnetic resonance imaging, when selected based on individual patient characteristics, may allow for improved decision-making and outcomes.
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Hanson et al. (2021) conducted a review in Stable ischemic heart disease (n=5,179). Initial invasive management strategy (medical therapy plus complete coronary revascularization) vs. Optimal medical therapy was evaluated on Composite of cardiovascular death, myocardial infarction, hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest (HR 0.93, 95% CI 0.80-1.08, p=0.34). An initial invasive strategy did not significantly reduce the composite of major cardiovascular events compared to optimal medical therapy in patients with stable ischemic heart disease and moderate to severe ischemia (HR 0.93).
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