Revascularization options in stable coronary artery disease: it is not how to revascularize, it is whether and when to revascularize

Abstract

Patients with acute coronary syndromes and severe multivessel or left main coronary artery disease have better outcomes when prompt revascularization is performed in addition to optimal medical therapy (OMT). However, in patients with stable ischemic heart disease, randomized strategy trials have revealed equipoise between initial strategies of OMT alone and OMT plus revascularization. Conducted in diverse stable ischemic heart disease patient populations and throughout the spectrum of atherosclerotic and ischemic burden, the RITA-2, MASS II, COURAGE, BARI 2D and FAME 2 trials demonstrate that OMT alone and OMT plus revascularization yield similar outcomes with respect to mortality and myocardial infarction. What remains unclear is whether there may be one or more subsets of patients with stable ischemic heart disease in whom revascularization may be associated with a reduction in mortality or myocardial infarction, which is to be addressed in the ongoing ISCHEMIA trial.

The ISCHEMIA Trial: What is the Message for the Interventionalist?

“…Invasive pressure wire studies have repeatedly demonstrated angiographic appearance relates poorly to ischaemia. [ 11 ] It is likely that prior studies will have included patients without ischaemia and thus revascularisation would give minimal benefit; such recruitment would dilute signals of benefit. Those studies that did seek ischaemia demonstrated only relatively limited levels of it.…”

“…This includes large randomised controlled studies, such as COURAGE, BARI2D and FAME 2. [ 11 – 13 ] Table 1 shows a summary of the key studies from 1992 to 2020.…”