Does ischemia burden in stable coronary artery disease effectively identify revascularization candidates? Ischemia burden in stable coronary artery disease does not effectively identify revascularization candidates.

Abstract

Over 30 years ago, a benefit of surgical revascularization was demonstrated in patients with stable ischemic heart disease (SIHD) but this was before most of our current disease-modifying medical therapies for coronary artery disease (CAD) were available.1 Analysis of these trials indicated that patients who derived the most benefit from surgery were those with more extensive CAD, particularly those with significant left main CAD or multivessel CAD, including proximal left anterior descending stenosis. After the introduction of percutaneous coronary intervention (PCI), studies were performed in the 1990s comparing PCI with contemporary medical therapy and found no benefit on death, myocardial infarction, or revascularization.2 It was at the time unclear whether this was because of the different revascularization technique or advances in medical therapy. See Response by Hachamovitch Subsequently, 2 large, randomized, multicenter trials were undertaken to determine whether revascularization offered an advantage over intensive medical therapy (optimal medical therapy). The Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) and Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI-2D) trials randomized patients with SIHD to a strategy of routine revascularization in addition to optimal medical therapy or to a strategy of optimal medical therapy alone.3,4 The optimal medical therapy approach included statin-based lipid-lowering therapy with a target low-density lipoprotein 60 to 85 mg/dL, anti-ischemic medications alone or in combination, and angiotensin-converting enzyme inhibition or angiotensin receptor blockade. The COURAGE trial included 2287 patients and used PCI as the revascularization technique. There was no benefit on the primary end point of death or myocardial infarction (MI) for the routine PCI strategy over a median 4.6 years of follow-up and there was also no difference between groups in survival. The BARI-2D trial included 2368 patients with diabetes mellitus and both PCI and surgery were used for revascularization. Randomization was …