External applicability of the ISCHEMIA trial: an analysis of a prospective, nationwide registry of patients with stable coronary artery disease

Luca, Leonardo De; Uguccioni, Massimo; Meessen, Jennifer; Temporelli, Pier Luigi; Tomai, Fabrizio; Rosa, Francesco Mario De; Passamonti, Enrico; Formigli, Dario; Riccio, Carmine; Gabrielli, Domenico; Colivicchi, Furio; Gulizia, Michele Massimo; Perna, Gian Piero

doi:10.4244/eij-d-20-00610

Cited by 26 publications

(11 citation statements)

References 18 publications

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“…In an analysis of the National Cardiovascular Data Registry CathPCI Registry representing contemporary practice in the USA, Chatterjee et al found that barely one-third of patients undergoing PCI for SIHD would have met enrollment criteria for the ISCHEMIA trial [ 27 ]. Similar findings were reported by De Luca and colleagues from Europe, with only 4% of patients undergoing PCI for SIHD meeting “ISCHEMIA-like” criteria [ 28 ]. Moreover, the actual denominator of eligible patients who were not enrolled in the trial is unknown as no such registry was maintained.…”

Section: Introductionsupporting

confidence: 87%

Ischemia Trial: Does the Cardiology Community Need to Pivot or Continue Current Practices?

Jafary

2022

Curr Cardiol Rep

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Purpose of Review For decades, the standard of care for stable ischemic heart disease (SIHD) has been an ischemia-centric approach based on largely observational data suggesting a survival benefit of revascularization in patients with moderate-or-severe ischemia. In this article, we will objectively review the evolution of the ischemia paradigm, the trial evidence comparing revascularization to medical therapy in SIHD, and what contemporary practice should be in 2022. Recent Findings Randomized trials, including COURAGE and, most recently, the ISCHEMIA trial, have shown no reduction in “hard outcomes” like death and myocardial infarction (MI) in SIHD compared to medical therapy. The trial excluded high-risk patients with left main disease, low ejection fraction (EF) < 35%, and severe unacceptable angina. Irrespective of the severity of ischemia and the extent of coronary artery disease (CAD), revascularization did not offer any prognostic advantage over medical therapy. On the other hand, there was a durable improvement in symptoms. While there are many caveats to the ISCHEMIA trial, the overall strengths of the trial outweigh these limitations. The findings of ISCHEMIA are consistent with previous trials. Summary It is time for the cardiology community to pivot towards medical therapy as the initial step for most patients with SIHD. Physicians should have the “COURAGE” to embrace “ISCHEMIA” and be comfortable with treating ischemia medically.

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Section: Introductionsupporting

confidence: 87%

Ischemia Trial: Does the Cardiology Community Need to Pivot or Continue Current Practices?

Jafary

2022

Curr Cardiol Rep

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“…Treatment effects of CABG and PCI as invasive therapies of CAD are currently hotly debated, as a life prolonging effect has recently been questioned by the "Initial Invasive or Conservative Strategy for Stable Coronary Disease" (ISCHEMIA trial) [26]. While the ISCHEMIA trial may only represent a small and very selective patient population [27], a large meta-analysis of all available evidence just demonstrated cardiac survival effects for revascularization (PCI and CABG combined) [28]. We reviewed the available evidence and linked survival impacts associated with CABG or PCI to mechanisms that prevent the occurrence of new myocardial infarctions or reperfuse ischemic myocardium [29,30].…”

Section: Discussionmentioning

confidence: 99%

Role of Concomitant Coronary Artery Bypass Grafting in Valve Surgery for Infective Endocarditis

Diab

Weber

Petrov

et al. 2021

JCM

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Background: It is current practice to perform concomitant coronary artery bypass grafting (CABG) in patients with infective endocarditis (IE) who have relevant coronary artery disease (CAD). However, CABG may add complexity to the operation. We aimed to investigate the impact of concomitant CABG on perioperative outcomes in patients undergoing surgery for IE. Methods: We retrospectively used data of surgically treated IE patients between 1994 and 2018 in six German cardiac surgery centers. We performed inverse probability weighting (IPW), multivariable adjustment, chi-square analysis, and Kaplan–Meier survival estimates. Results: CAD was reported in 1242/4917 (25%) patients. Among them, 527 received concomitant CABG. After adjustment for basal characteristics between CABG and no-CABG patients using IPW, concomitant CABG was associated with higher postoperative stroke (26% vs. 21%, p = 0.003) and a trend towards higher postoperative hemodialysis (29% vs. 25%, p = 0.052). Thirty-day mortality was similar in both groups (24% vs. 23%, p = 0.370). Multivariate Cox regression analysis after IPW showed that CABG was not associated with better long-term survival (HR: 1.00, 95% CI: 0.82–1.23, p = 0.998). Conclusion: In endocarditis patients with CAD, adding CABG to valve surgery may be associated with a higher likelihood of postoperative stroke without adding long-term survival benefits. Therefore, in the absence of critical CAD, concomitant CABG may be omitted without impacting outcome. The results are limited due to a lack of data on the severity of CAD, and therefore there is a need for a randomized trial.

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“…In fact, a subsequent prospective registry trial suggests that only around 4% of patients in a contemporary real-world cohort of patients with CCS would be eligible for enrolment and randomisation in ISCHEMIA. [4] Including patients only with non-invasively proven moderate to severe myocardial ischemia, the inclusion of revascularisation by means of CABG, only utilising latest generation drug eluting stents and anatomical results of the CTCA being blinded to the investigators are all important assets of the ISCHEMIA trial. However, regarding non-invasively proven myocardial ischaemia, protocol al-lowed various modalities for non-invasive assessments of myocardial ischemia, including exercise tolerance testing, stress echocardiography, stress perfusion cardiac magnetic resonance imaging and nuclear imaging.…”

Section: Ischemia Versus Clinical Reality Of Patients With Ccsmentioning

confidence: 99%

Clinical application of results of the ISCHEMIA trial

Schnur¹,

Achim²,

Tóth³

2023

Trends in Cardiovascular Medicine

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External applicability of the ISCHEMIA trial: an analysis of a prospective, nationwide registry of patients with stable coronary artery disease

Cited by 26 publications

References 18 publications

Ischemia Trial: Does the Cardiology Community Need to Pivot or Continue Current Practices?

Ischemia Trial: Does the Cardiology Community Need to Pivot or Continue Current Practices?

Role of Concomitant Coronary Artery Bypass Grafting in Valve Surgery for Infective Endocarditis

Clinical application of results of the ISCHEMIA trial

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