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Impact of Complete Revascularization in the ISCHEMIA Trial
Gregg W Stone1, Ziad A Ali2, Sean M O'Brien3
1The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
Insights
Achieving anatomic complete revascularization (ACR) in invasive management for chronic coronary disease significantly reduces cardiovascular death or myocardial infarction (MI). Invasive strategies may offer improved outcomes when ACR is successfully achieved.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Clinical Trials
Background:
- Anatomic complete revascularization (ACR) and functional complete revascularization (FCR) are linked to better outcomes in prior studies.
- The comparative impact of complete revascularization (CR) within invasive versus conservative management strategies for chronic coronary disease remains unclear.
Purpose of the Study:
- To evaluate the outcomes of ACR and FCR compared to incomplete revascularization in patients with chronic coronary disease.
- To assess the impact of achieving CR in all invasive patients versus conservative management using data from the ISCHEMIA trial.
Main Methods:
- Analysis of ACR and FCR rates in 1,824 invasive patients from the ISCHEMIA trial.
- Multivariable-adjusted outcomes of CR were examined in invasive patients.
- Inverse probability weighted modeling was used to compare CR in invasive patients versus conservative management.
Main Results:
- ACR was achieved in 43.4% and FCR in 58.4% of invasive patients.
- ACR was associated with reduced 4-year rates of cardiovascular death or myocardial infarction (MI) compared to incomplete revascularization.
- Inverse probability weighted modeling showed ACR in all invasive patients was associated with a lower 4-year rate of cardiovascular death or MI compared to conservative management (-3.5% difference).
Conclusions:
- Achieving complete revascularization, particularly ACR, may improve outcomes for patients managed invasively.
- The findings suggest that optimizing revascularization completeness is crucial for maximizing the benefits of invasive strategies in chronic coronary disease.
Background:
Anatomic complete revascularization (ACR) and functional complete revascularization (FCR) have been associated with reduced death and myocardial infarction (MI) in some prior studies. The impact of complete revascularization (CR) in patients undergoing an invasive (INV) compared with a conservative (CON) management strategy has not been reported.
Objectives:
Among patients with chronic coronary disease without prior coronary artery bypass grafting randomized to INV vs CON management in the ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial, we examined the following: 1) the outcomes of ACR and FCR compared with incomplete revascularization; and 2) the potential impact of achieving CR in all INV patients compared with CON management.
Methods:
ACR and FCR in the INV group were assessed at an independent core laboratory. Multivariable-adjusted outcomes of CR were examined in INV patients. Inverse probability weighted modeling was then performed to estimate the treatment effect had CR been achieved in all INV patients compared with CON management.
Results:
ACR and FCR were achieved in 43.4% and 58.4% of 1,824 INV patients. ACR was associated with reduced 4-year rates of cardiovascular death or MI compared with incomplete revascularization. By inverse probability weighted modeling, ACR in all 2,296 INV patients compared with 2,498 CON patients was associated with a lower 4-year rate of cardiovascular death or MI (difference -3.5; 95% CI: -7.2% to 0.0%). In comparison, the event rate difference of cardiovascular death or MI for INV minus CON in the overall ISCHEMIA trial was -2.4%. Results were similar but less pronounced with FCR.
Conclusions:
The outcomes of an INV strategy may be improved if CR (especially ACR) is achieved. (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches [ISCHEMIA]; NCT01471522).
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