ISCHEMIA trial - Failed intervention or failed stratification?

Treatment of stable ischemic heart disease remains controversial due to lack of proper measures to identify the vulnerable patient who will suffer acute coronary events. Imaging modalities can identify rupture-prone coronary plaques but studies have found that most plaque ruptures without causing clinical events (1). High risk plaques identified by CT Angiogram (CTA) was found to be predictive of acute coronary events (ACS) in a large cohort study but the extent of atherosclerotic burden was a confounder (2). As such, numerous studies have suggested total atherosclerotic plaque burden as the main determinant of adverse patient outcomes (3,4). Coronary artery calcium (CAC) is a highly specific surrogate for coronary atherosclerosis burden and is the most predictive single cardiovascular risk marker in asymptomatic persons (5). The greater the atherosclerotic plaque burden, the more likely plaque ruptures will occur and the greater the probability that one of them triggers vascular thrombosis and a clinical event (6).