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Initial Invasive or Conservative Strategy for Stable Coronary Disease.

David J Maron1, Judith S Hochman1, Harmony R Reynolds1

  • 1From the Department of Medicine, Stanford University School of Medicine, Stanford (D.J.M., R.A.H.), and Cedars-Sinai Medical Center, Los Angeles (D.S.B.) - both in California; New York University Grossman School of Medicine (J.S.H., H.R.R., S. Bangalore, J.S.B., J.D.N., S.M.), Weill Cornell Medicine/New York-Presbyterian Hospital (L.J.S.), Cleerly (J.K.M.), the Cardiovascular Research Foundation (Z.A.A., G.W.S.), Columbia University Irving Medical Center/New York-Presbyterian Hospital (Z.A.A.), and Icahn School of Medicine at Mount Sinai (G.W.S.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; Duke Clinical Research Institute, Durham (S.M.O., K.P.A., R.D.L., D.B.M., F.W.R., S. Broderick), and Brody School of Medicine, East Carolina University, Greenville (T.B.F.) - both in North Carolina; Veterans Affairs (VA) New England Healthcare System and Boston University School of Medicine (W.E.B.), Massachusetts General Hospital and Harvard Medical School (M.H.P.), and Brigham and Women's Hospital (R.Y.K., D.O.W.) - all in Boston; Saint Louis University School of Medicine, St. Louis (B.R.C.), and the Saint Luke's Mid America Heart Institute and the University of Missouri-Kansas City School of Medicine, Kansas City (J.A.S.); Northwick Park Hospital (R.S., A.E.) and Imperial College London and Royal Brompton Hospital (R.S.) - all in London; Hospital Universitario La Paz, Instituto de Investigación de La Paz, Centro de Investigación Biomédica en Red Cardiovascular, Madrid (J.L.-S.), and Complejo Hospitalario Universitario A Coruna, Centro de Investigación Biomédica en Red Cardiovascular, A Coruna (J.P.) - all in Spain; Canadian Heart Research Centre and St. Michael's Hospital, University of Toronto, Toronto (S.G.G.), Montreal Heart Institute Research Center, Montreal (G.G.), and the University of British Columbia, Vancouver (G.B.J.M.) - all in Canada; the Department of Coronary and Structural Heart Diseases (M.D.), National Institute of Cardiology (W.R., M.D., H.S.), Warsaw, Poland; Associazione Nazionale Medici Cardiologi Ospedalieri, Florence, Italy (A.P.M.); Auckland Hospital Green Lane Cardiovascular Services, Auckland, New Zealand (H.D.W.); All India Institute of Medical Sciences, New Delhi (B.B.), Government Medical College Kozhikode, Kerala (M.N.K.), and Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore (N.M.) - all in India; Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Faculdade de Medicina, Universidade de São Paulo, São Paulo (W.A.H.); Emory University School of Medicine-Atlanta VA Medical Center, Decatur, Georgia (K.M.); the National Research Center for Cardiovascular Surgery, Moscow (O.B.); Mayo Clinic, Rochester, MN (T.D.M.); Praxisklinik Herz und Gefaesse, Dresden, Germany (R.D.); Semmelweis University, Budapest, Hungary (M.K.); Flinders University, Flinders Medical Centre, Adelaide, SA, Australia (J.B.S.); Université de Paris, Assistance Publique-Hôpitaux de Paris, and INSERM Unité 1148, Paris (P.G.S.); the Department of Medical Sciences, Cardiology, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden (C.H.); Keio University School of Medicine, Shinjuku, Tokyo (S.K.); the National Institutes of Health, Bethesda, MD (R.K., N.O.J., Y.R.); and Vanderbilt University School of Medicine, Nashville (F.E.H.).

The New England Journal of Medicine
|April 1, 2020
PubMed
Summary
This summary is machine-generated.

For stable coronary disease with ischemia, an invasive strategy did not significantly reduce ischemic events compared to conservative medical therapy. Further research is needed to clarify the role of invasive procedures in managing coronary artery disease.

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Area of Science:

  • Cardiology
  • Interventional Cardiology
  • Clinical Trials

Background:

  • Stable coronary artery disease (CAD) with moderate to severe ischemia presents a clinical dilemma regarding optimal management.
  • Uncertainty exists whether an invasive strategy (angiography and revascularization) plus medical therapy offers better outcomes than medical therapy alone.

Purpose of the Study:

  • To compare clinical outcomes between an initial invasive strategy and an initial conservative strategy in patients with stable CAD and moderate or severe ischemia.
  • To evaluate the efficacy of early revascularization versus optimal medical therapy in preventing major adverse cardiovascular events.

Main Methods:

  • A randomized trial involving 5179 patients with moderate to severe ischemia.
  • Patients were assigned to either an initial invasive strategy (angiography and revascularization) or an initial conservative strategy (medical therapy alone, with angiography if therapy failed).
  • The primary outcome was a composite of cardiovascular death, myocardial infarction, or specific hospitalizations; a key secondary outcome was cardiovascular death or myocardial infarction.

Main Results:

  • Over a median of 3.2 years, no significant difference in the primary composite outcome was observed between the invasive and conservative groups (16.4% vs. 18.2% at 5 years).
  • Key secondary outcomes also showed no significant differences.
  • The incidence of myocardial infarction was sensitive to its definition, with more procedural MIs in the invasive group.
  • There were no significant differences in all-cause mortality between the groups.

Conclusions:

  • An initial invasive strategy did not reduce the risk of ischemic cardiovascular events or death compared to an initial conservative strategy in patients with stable CAD and moderate or severe ischemia.
  • Trial findings were sensitive to the definition of myocardial infarction used.
  • The results suggest that optimal medical therapy may be sufficient for many patients with stable CAD and ischemia, reserving invasive procedures for specific indications.