ISCHEMIA: Invasive Treatment Not Better Than Meds in Patients with Stable Ischemic Heart Disease

By Amy Orciari Herman

Edited by Susan Sadoughi, MD, and André Sofair, MD, MPH

In patients with stable ischemic heart disease, invasive treatment appears no better than optimal medical therapy for preventing cardiovascular (CV) events, according to the international ISCHEMIA trial. The findings were presented on Saturday at the American Heart Association's annual meeting in Philadelphia.

Nearly 5200 adults with stable ischemic heart disease and moderate-to-severe ischemia (usually diagnosed by stress imaging) were randomized to invasive or conservative management. In the invasive group, patients underwent cardiac catheterization followed by percutaneous coronary intervention or coronary artery bypass grafting, when feasible; they also received optimal medical therapy. The conservative group received optimal medical therapy alone. Of note, patients with left main disease were excluded.

At 4 years, incidence of the primary endpoint — a composite of CV death, myocardial infarction (MI), resuscitated cardiac arrest, hospitalization for unstable angina, or heart failure — did not differ significantly between the invasive and conservative groups (13.3% and 15.5%, respectively). A major secondary endpoint comprising CV death or MI also did not differ significantly (11.7% and 13.9%).

Dr. Harlan Krumholz, editor-in-chief of NEJM Journal Watch Cardiology, offered his take: "The ISCHEMIA study is a lot to digest — and the results haven't yet been published in a peer-reviewed journal. Yet, what seems clear is that patients with stable ischemic disease are safe with medical therapy, which is consistent with many other studies. A side question is whether stress myocardial perfusion studies are providing much value for these patients."