The ISCHEMIA Trial: Invasive vs. Conservative Initial Management for Stable Coronary Artery Disease

In early 2020, a seminal trial (the ISCHEMIA trial) provided insights into initial management of stable coronary artery disease. Investigators randomized more than 5100 patients (median age 64; 77% men) with stable coronary disease and moderate-to-severe ischemia on stress testing to either guideline-directed medical management or revascularization plus medical management. Most patients underwent computed tomography angiography (CTA) to exclude left main disease prior to randomization. At baseline, 35% of patients had no angina (NEJM JW Gen Med May 1 2020 and N Engl J Med 2020; 382:1395, 1408).

During the first year of follow-up, a composite endpoint (i.e., cardiovascular-related death; myocardial infarction [MI]; or hospitalization for unst…