What does this research mean for the field?

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 to optimized medical therapy, though its specific applicability to chronic total occlusions requires an integrated decision-making model. Novelty: ClaimNovelty.SYNTHESIS. Consensus alignment: ConsensusAlignment.NEUTRAL.

What question did this study set out to answer?

To evaluate the efficacy of percutaneous coronary intervention (CTO-PCI) for chronic total coronary occlusions compared to conservative treatment in patients with coronary artery disease.

March 13, 2026

Percutaneous coronary intervention or conservative therapy for chronic total coronary occlusions (CTOs)? Evidence from the ISCHEMIA Trial

Key Result

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

Key Points

To evaluate the efficacy of percutaneous coronary intervention (CTO-PCI) for chronic total coronary occlusions compared to conservative treatment in patients with coronary artery disease.
Critical analysis of the ISCHEMIA Trial and its CTO sub-study.
Comparative review of dedicated CTO-PCI studies.
Proposed integrated decision-making model involving symptom control and imaging.
Initial invasive strategy did not reduce cardiovascular mortality compared to optimized medical therapy.
Myocardial infarction rates were similar between the two treatment approaches.
Majority of enrolled patients in the ISCHEMIA Trial did not undergo CTO revascularization.

Structured PICO

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?

Population

Patients with stable coronary artery disease and moderate-to-severe ischaemia, specifically focusing on those with chronic total coronary occlusions (CTOs)

Intervention

Initial invasive strategy (percutaneous coronary intervention for CTOs / CTO-PCI)

Comparator

Optimised medical therapy / conservative therapy

Outcome

Cardiovascular mortality or myocardial infarctionhard clinical

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.

Main Result

Absolute Event Rate: 0% vs 0%

Abstract

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.

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Cite This Study

Madaudo et al. (Mon,) reported a other. 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.

synapsesocial.com/papers/69b3ab6e02a1e69014ccc4af https://doi.org/https://doi.org/10.1093/eurheartjsupp/suag033

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