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Deciding Between Invasive and Conservative Strategies for Patients with Moderate Ischemia

In This Article

  • The ISCHEMIA trial, which evaluated invasive vs. conservative strategies in patients with stable ischemic heart disease, was a highlight of the 2019 American Heart Association Scientific Sessions
  • The results of the trial showed similar clinical outcomes between the two groups
  • Darshan Doshi, MD, interventional cardiologist at Massachusetts General Hospital, discusses the professional debate that spawned from the trial and shares an interventionist perspective on the implications for treating patients

The results of the ISCHEMIA trial, which were presented at the 2019 American Heart Association Scientific Sessions, showed that patients with stable ischemic heart disease had similar outcomes whether they were assigned the invasive strategy or the conservative strategy.

In the trials, patients assigned the invasive strategy received optimal medical therapy plus diagnostic catheterization and underwent percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) based on the results of the catheterization. Patients assigned the conservative strategy received optimal medical therapy alone and diagnostic catheterization if they failed the medical therapy.

According to Darshan Doshi, MD, interventional cardiologist in the Corrigan Minehan Heart Center at Massachusetts General Hospital, the most important takeaway from the trial results is that there is a clinical equipoise among cardiologists between the two strategies for management of patients with moderate ischemia by stress testing.

The results of the trial revealed that for some endpoints, the invasive strategy appears worse initially; but after two years, it becomes favorable, based on lower rates of spontaneous myocardial infarctions and hospitalizations for unstable angina. Because of this distinction, Dr. Doshi suggested that the invasive strategy is no worse than the conservative strategy and could lead to more significant relief for symptomatic patients.

Dr. Doshi also suggested that cardiologists need to understand the patient and their risk factors prior to conducting stress tests. The protocol of the trials resulted in the exclusion of over 400 patients who had left main disease. For these patients, medical therapy alone may not be an effective treatment.

While patients with no to mild ischemia may be suitably treated with medical therapy, Dr. Doshi recommended that patients with moderate to severe ischemia undergo a CTA or cardiac catheterization to test for left main disease. If left main disease is present, he recommends that cardiologists then determine whether it is appropriate to assign either optimal medical therapy alone or revascularization with optimal medical therapy. He said that for patients who are overtly symptomatic, however, the invasive strategy is likely warranted considering the improvements in anginal symptoms and quality of life shown in the trial results.

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Michael Picard, MD, cardiologist in the Corrigan Minehan Heart Center, discusses the outcomes of the ISCHEMIA trial, for which he interpreted the stress echocardiograms. The trial studied the benefits of medical therapy or more invasive strategies for patients with stable forms of ischemic heart disease.


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