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Ischemia Trial: Does the Cardiology Community Need to Pivot or Continue Current Practices?

Fahim H Jafary1, Ali H Jafary2

  • 1Department of Cardiology NHG Heart Institute, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore. jafary@pobox.com.

Current Cardiology Reports
|June 2, 2022
PubMed

Insights

For stable ischemic heart disease (SIHD), revascularization does not improve survival compared to medical therapy. Recent trials show symptom improvement with revascularization, but medical management should be the initial approach for most SIHD patients.

Area of Science:

  • Cardiology
  • Clinical Medicine
  • Interventional Cardiology

Background:

  • The traditional approach to stable ischemic heart disease (SIHD) prioritized revascularization based on observational data.
  • This ischemia-centric model suggested survival benefits from procedures in patients with moderate-to-severe ischemia.

Purpose of the Study:

  • To review the evolution of the ischemia paradigm in SIHD.
  • To analyze trial evidence comparing revascularization with medical therapy.
  • To define contemporary practice guidelines for SIHD in 2022.

Main Methods:

  • Review of randomized controlled trials, including COURAGE and ISCHEMIA.
  • Analysis of comparative effectiveness of revascularization versus medical therapy for SIHD.
  • Evaluation of patient outcomes, including hard endpoints and symptoms.

Main Results:

  • Randomized trials demonstrated no significant reduction in mortality or myocardial infarction (MI) with revascularization compared to medical therapy in SIHD.
  • Revascularization provided durable improvement in symptoms, but not prognostic advantage.
  • The ISCHEMIA trial's findings align with previous research, despite certain trial limitations.

Conclusions:

  • Current evidence suggests medical therapy should be the initial treatment strategy for the majority of SIHD patients.
  • Revascularization does not offer a survival benefit over optimal medical therapy for SIHD.
  • Cardiologists should embrace medical therapy as the primary management for SIHD, reserving revascularization for specific indications.
Abstract

Keywords:
IschemiaMedical therapyRevascularizationStable ischemic heart disease

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