Application and clinical implications of revascularization on chronic coronary syndromes: From COURAGE to ISCHEMIA trial

The proper treatment of chronic coronary syndromes (CCS), formerly referred to as stable coronary artery disease (SCAD), remains an endless debate. Whether optimal medical treatment along with modification of well-established risk factors is enough, or invasive procedures also have a role in CCS, has been the object of noteworthy randomized studies with controversial results. Recently, the ISCHEMIA study failed to show any meaningful benefit of the interventional approach in patients with CCS and moderate to severe ischemia. There was no statistically significant difference in the composite primary endpoint of myocardial infarction (MI), cardiovascular (CV) death, hospitalization for unstable angina or cardiac failure and resuscitation due to cardiac arrest, between the groups of initial invasive strategy and initial conservative approach. The hard secondary endpoints of MI, CV death and death from all causes also did not differ significantly between the two arms. However, there are cases of patients suffering from refractory angina or with significant burden of ischemia in non-invasive testing that have not been included in the trial, where invasive approach may have a role in improving quality of life or even in decreasing the risk of a coronary event. It is important to distinguish these patients from the all-comers “stable” ones in our catheterization laboratories. Finally, a hemodynamically severe stenosis is not always the only reason for ischemia reflecting the importance of the microvascular bed in clinical presentation. Interpretation of coronary physiology has a very important role and may lead to more proper treatment decisions in the catheterization laboratory.