Abstract
Purpose of reviewThis 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 findingsThe 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.SummaryThe 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.
Highlights
The evaluation and management of coronary artery disease (CAD) have been challenging physicians for centuries
In an ad hoc analysis of patients enrolled in the ISCHEMIA trial found that few clinical and stress testing parameters were predictive of left main (LM) disease on coronary computed tomographic angiography (CCTA) in patients with moderate or severe ischemia on stress testing [14]
The landmark results of the ISCHEMIA trial have provided more evidence against the prevailing dogma that moderate to severe ischemia warrants routine coronary revascularization
Summary
The evaluation and management of coronary artery disease (CAD) have been challenging physicians for centuries. The major limitations of this trial were its relatively small sample size and slow enrollment, lower than anticipated adverse events rates in both groups, a 23% crossover rate of medical therapy to the revascularization, high utilization of (25%) of ExECG alone without imaging, low proportion of women (23%), and relatively short follow-up at 3.2 median years. Only 35% participants reported experiencing any angina in the 4 weeks prior to enrollment Despite these limitations, the results of this landmark clinical trial add significantly to a growing body of literature questioning the routine use of coronary revascularization to prevent hard cardiac events in patients with stable symptoms—even in those with moderate to severe ischemia—when aggressive medical therapy is
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