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

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.