1932

Abstract

The recent landmark International Study of Comparative Health Effectiveness With Medical and Invasive Approaches (ISCHEMIA) trial was undertaken to assess whether stable angina patients with moderate to severe baseline ischemia would benefit from an invasive approach with revascularization versus a conservative approach of intensive lifestyle intervention and pharmacologic secondary prevention. This trial addressed the hypothesis that treating ischemia with an invasive approach would reduce major adverse cardiac events more than a noninvasive pharmacologic and lifestyle approach. ISCHEMIA is discussed in detail, along with current implications for contemporary management of this very common cardiac disorder afflicting millions of patients worldwide.

Loading

Article metrics loading...

/content/journals/10.1146/annurev-med-042921-124013
2023-01-27
2024-04-30
Loading full text...

Full text loading...

/deliver/fulltext/med/74/1/annurev-med-042921-124013.html?itemId=/content/journals/10.1146/annurev-med-042921-124013&mimeType=html&fmt=ahah

Literature Cited

  1. 1.
    Maron DJ, Hochman JS, Reynolds HR et al. 2020. Initial invasive or conservative strategy for stable coronary disease. N. Engl. J. Med. 382:151395–407
    [Google Scholar]
  2. 2.
    Takaro T, Hultgren HN, Lipton MJ, Detre KM. 1976. The VA cooperative randomized study of surgery for coronary arterial occlusive disease II. Subgroup with significant left main lesions. Circulation 54:6 Suppl.III107–17
    [Google Scholar]
  3. 3.
    Yusuf S, Zucker D, Peduzzi P et al. 1994. Effect of coronary artery bypass graft surgery on survival: overview of 10-year results from randomised trials by the Coronary Artery Bypass Graft Surgery Trialists Collaboration. Lancet 344:8922563–70
    [Google Scholar]
  4. 4.
    Parisi AF, Folland ED, Hartigan P. 1992. A comparison of angioplasty with medical therapy in the treatment of single-vessel coronary artery disease. N. Engl. J. Med. 326:110–16
    [Google Scholar]
  5. 5.
    RITA-2 Trial Participants 1997. Coronary angioplasty versus medical therapy for angina: the second Randomised Intervention Treatment of Angina (RITA-2) trial. Lancet 350:9076461–68
    [Google Scholar]
  6. 6.
    Boden WE, O'Rourke RA, Teo KK et al. 2007. Optimal medical therapy with or without PCI for stable coronary disease. N. Engl. J. Med. 356:151503–16
    [Google Scholar]
  7. 7.
    BARI 2D Study Group 2009. A randomized trial of therapies for type 2 diabetes and coronary artery disease. N. Engl. J. Med. 360:242503–15
    [Google Scholar]
  8. 8.
    De Bruyne B, Pijls NH, Kalesan B et al. 2012. Fractional flow reserve-guided PCI versus medical therapy in stable coronary disease. N. Engl. J. Med. 367:11991–1001
    [Google Scholar]
  9. 9.
    Stergiopoulos K, Boden WE, Hartigan P et al. 2014. Percutaneous coronary intervention outcomes in patients with stable obstructive coronary artery disease and myocardial ischemia: a collaborative meta-analysis of contemporary randomized clinical trials. JAMA Intern. Med. 174:2232–40
    [Google Scholar]
  10. 10.
    Hachamovitch R, Hayes SW, Friedman JD et al. 2003. Comparison of the short-term survival benefit associated with revascularization compared with medical therapy in patients with no prior coronary artery disease undergoing stress myocardial perfusion single photon emission computed tomography. Circulation 107:232900–7
    [Google Scholar]
  11. 11.
    Hachamovitch R, Rozanski A, Shaw LJ et al. 2011. Impact of ischaemia and scar on the therapeutic benefit derived from myocardial revascularization versus medical therapy among patients undergoing stress-rest myocardial perfusion scintigraphy. Eur. Heart J. 32:81012–24
    [Google Scholar]
  12. 12.
    Al-Lamee R, Thompson D, Dehbi HM et al. 2018. Percutaneous coronary intervention in stable angina (ORBITA): a double-blind, randomised controlled trial. Lancet 391:1011531–40
    [Google Scholar]
  13. 13.
    Spertus JA, Jones PG, Maron DJ et al. 2020. Health-status outcomes with invasive or conservative care in coronary disease. N. Engl. J. Med. 382:151408–19
    [Google Scholar]
  14. 14.
    Maron DJ, Hochman JS, O'Brien SM et al. 2018. International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) trial: rationale and design. Am. Heart J. 201:124–35
    [Google Scholar]
  15. 15.
    Stone GW, Maehara A, Lansky AJ et al. 2011. A prospective natural-history study of coronary atherosclerosis. N. Engl. J. Med. 364:3226–35
    [Google Scholar]
  16. 16.
    Reynolds HR, Shaw LJ, Min JK et al. 2020. Association of sex with severity of coronary artery disease, ischemia, and symptom burden in patients with moderate or severe ischemia: secondary analysis of the ISCHEMIA randomized clinical trial. JAMA Cardiol. 5:7773–86
    [Google Scholar]
  17. 17.
    Bangalore S, Maron DJ, O'Brien SM et al. 2020. Management of coronary disease in patients with advanced kidney disease. N. Engl. J. Med. 382:171608–18
    [Google Scholar]
  18. 18.
    Spertus JA, Jones PG, Maron DJ et al. 2020. Health status after invasive or conservative care in coronary and advanced kidney disease. N. Engl. J. Med. 382:171619–28
    [Google Scholar]
  19. 19.
    Fihn SD, Gardin JM, Abrams J et al. 2012. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J. Am. Coll. Cardiol. 60:242564–603
    [Google Scholar]
  20. 20.
    Douglas PS, Hoffmann U. 2015. Anatomical versus functional testing for coronary artery disease. N. Engl. J. Med. 373:189–91
    [Google Scholar]
  21. 21.
    Shreibati JB, Baker LC, Hlatky MA. 2011. Association of coronary CT angiography or stress testing with subsequent utilization and spending among Medicare beneficiaries. JAMA 306:192128–36
    [Google Scholar]
  22. 22.
    Newby DE, Adamson PD, Berry C et al. 2018. Coronary CT angiography and 5-year risk of myocardial infarction. N. Engl. J. Med. 379:10924–33
    [Google Scholar]
  23. 23.
    Moss AJ, Williams MC, Newby DE, Nicol ED. 2017. The updated NICE guidelines: cardiac CT as the first-line test for coronary artery disease. Curr. Cardiovasc. Imaging Rep. 10:515
    [Google Scholar]
  24. 24.
    Poon M, Lesser JR, Biga C et al. 2020. Current evidence and recommendations for coronary CTA first in evaluation of stable coronary artery disease. J. Am. Coll. Cardiol. 76:111358–62
    [Google Scholar]
  25. 25.
    Boden WE, Kaski JC, Al-Lamee R, Weintraub WS 2022. What constitutes an appropriate empirical trial of antianginal therapy in patients with stable angina before referral for revascularisation?. Lancet 399:10325691–94
    [Google Scholar]
  26. 26.
    Boden WE, Stone PH. 2021. To stent or not to stent? Treating angina after ISCHEMIA—why a conservative approach with optimal medical therapy is the preferred initial management strategy for chronic coronary syndromes: insights from the ISCHEMIA trial. Eur. Heart J. 42:141394–400
    [Google Scholar]
/content/journals/10.1146/annurev-med-042921-124013
Loading
/content/journals/10.1146/annurev-med-042921-124013
Loading

Data & Media loading...

  • Article Type: Review Article
This is a required field
Please enter a valid email address
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error