Impact of ISCHEMIA Trial on Clinical Practice

Abstract

ISCHEMIA (Initial Invasive or Conservative Strategy for Stable Coronary artery disease) trial was a large, international, multi center, prospective, randomized controlled clinical trial comparing initial invasive plus optimal medical therapy (OMT) strategy versus conservative management plus OMT strategy in stable coronary artery disease patients with moderate to severe ischemia. It is still too early to describe the overall impact of ISCHEMIA trial partly because the result is still in the process of slowly being digested in the cardiology and general communities, but also because COVID-19 pandemic has greatly altered recent cardiology practices in the US and worldwide. However, one thing is very likely. Based on the result of this trial, cardiologists will be asked more often to be cautious about indications for revascularization. A proof of ischemia alone cannot be justified for initial invasive strategy in a stable coronary artery disease patients who are optimally medically managed and asymptomatic or minimally symptomatic. In the early days of angioplasties, “Oculo-stenotic reflex” was frowned upon as a too premature attitude of angioplasty treatment for an anatomically significant coronary stenosis but otherwise unknown hemodynamic or clinical importance. After the ISCHEMIA trial, cardiologists may be asked to shy away from “Ischemia-invasive reflex” in the appropriate context in stable coronary artery disease patients who are optimally medically treated and asymptomatic or minimally symptomatic. According to the result of this trial, proof of significant ischemia is not a “ Carte Blanche ” for early invasive management strategy. On the other hand, this trial did show durable improvement of angina symptoms in the invasive arm compared to conservative arm, thus, as long as the goal of the management is clearly stated to reduce angina and to improve quality of life, early invasive strategy for stable coronary artery disease patients is justifiable in the post ISCHEMIA era. angiogram performed before randomization to exclude unpro-tected left main disease and non-obstructive coronary artery disease. Severe left ventricular systolic dysfunction with ejection fraction <35%, chronic kidney disease patients with GFR below 30 ml/min/1.73 m 2 , recent acute coronary syndrome patients, de-compensated heat failure, and unstable angina patients were also excluded.