Related Experiment Video
Updated: Sep 27, 2025
Postconditioning with Lactate-enriched Blood for Cardioprotection in ST-segment Elevation Myocardial Infarction
Published on: May 28, 2019
Outcomes With Intermediate Left Main Disease: Analysis From the ISCHEMIA Trial
Sripal Bangalore1, John A Spertus2, Susanna R Stevens3
1Department of Medicine, New York University Grossman School of Medicine (S.B., H.R.R., J.S.B., J.S.H.).
Insights
Intermediate left main disease (LMD) did not significantly alter invasive strategy benefits in the ISCHEMIA trial. However, invasive management reduced nonprocedural myocardial infarction in patients with intermediate LMD.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Trials
Background:
- Significant left main disease (LMD) (≥50% stenosis) poses a high cardiovascular risk, necessitating revascularization.
- The clinical impact of intermediate LMD (25%-49% stenosis) on patient outcomes remains incompletely understood.
Purpose of the Study:
- To investigate the outcomes of patients with and without intermediate left main disease (LMD) within the ISCHEMIA trial.
- To assess the impact of an invasive revascularization strategy on these outcomes, considering the presence of intermediate LMD.
Main Methods:
- Analysis of patients from the ISCHEMIA trial who underwent baseline coronary computed tomography angiography.
- Categorization of patients into groups with intermediate LMD (25%-49%) and without (<25%) LMD.
- Comparison of primary composite outcomes (cardiovascular death, MI, hospitalization) and quality of life (Seattle Angina Questionnaire score) between groups and treatment strategies.
Main Results:
- 26% of participants had intermediate LMD; 7% of those with intermediate LMD on CT angiography had significant LMD on invasive angiography.
- Patients with intermediate LMD showed a higher unadjusted risk of cardiovascular events, but this was not significant after full adjustment.
- An invasive strategy increased procedural MI but decreased nonprocedural MI, with no significant difference in the primary endpoint. A significant interaction was observed for nonprocedural MI, with a greater reduction in the intermediate LMD group.
Conclusions:
- The ISCHEMIA trial found no significant heterogeneity in the treatment benefit of an invasive strategy based on intermediate LMD status, except for a greater reduction in nonprocedural MI.
- An invasive strategy in patients with intermediate LMD increased procedural MI, reduced nonprocedural MI, and improved angina-related quality of life.
- These findings suggest that intermediate LMD does not preclude the benefits of an invasive approach, particularly regarding nonprocedural MI reduction and quality of life improvements.
Background:
Patients with significant (≥50%) left main disease (LMD) have a high risk of cardiovascular events, and guidelines recommend revascularization to improve survival. However, the impact of intermediate LMD (stenosis, 25%-49%) on outcomes is unclear.
Methods:
Randomized ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) participants who underwent coronary computed tomography angiography at baseline were categorized into those with (25%-49%) and without (<25%) intermediate LMD. The primary outcome was a composite of cardiovascular mortality, myocardial infarction (MI), or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. The primary quality of life outcome was the Seattle Angina Questionnaire summary score.
Results:
Among the 3699 participants who satisfied the inclusion criteria, 962 (26%) had intermediate LMD. Among invasive strategy participants with intermediate LMD on coronary computed tomography angiography, 49 (7.0%) had significant (≥50% stenosis) left main stenosis on invasive angiography. Patients with intermediate LMD had a higher risk of cardiovascular events in the unadjusted but not in the fully adjusted model compared with those without intermediate LMD. An invasive strategy increased procedural MI and decreased nonprocedural MI with no significant difference for other outcomes including the primary end point. There was no meaningful heterogeneity of treatment effect based on intermediate LMD status except for nonprocedural MI for which there was a greater absolute reduction with invasive management in the intermediate LMD group (-6.4% versus -2.0%; Pinteraction=0.049). The invasive strategy improved angina-related quality of life and the benefit was durable throughout follow-up without significant heterogeneity based on intermediate LMD status.
Conclusions:
In the ISCHEMIA trial, there was no meaningful heterogeneity of treatment benefit from an invasive strategy regardless of intermediate LMD status except for a greater absolute risk reduction in nonprocedural MI with invasive management in those with intermediate LMD. An invasive strategy increased procedural MI, reduced nonprocedural MI, and improved angina-related quality of life.
Registration:
URL: https://www.
Clinicaltrials:
gov; Unique identifier: NCT01471522.
Related Concept Videos
01:30Acute Coronary Syndrome III: Diagnostic Studies
01:17Ischemic Heart Disease: Overview
Atherosclerosis, the primary malefactor, orchestrates this dangerous condition. It manifests as the accumulation of fatty deposits, akin to insidious plaques, within arterial walls. As time elapses, these plaques metamorphose, hardening and...
01:30Coronary Artery Disease III: Clinical Manifestations