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Revascularization Strategies in Stable Coronary Artery Disease: ISCHEMIA Trial Insights

05 Mar 2024

In the ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial, researchers examined the risk of ischemic events in patients with stable coronary artery disease. The study evaluated outcomes associated with an invasive strategy involving angiography and percutaneous coronary intervention (PCI) or surgical coronary artery bypass grafting (CABG), compared to a conservative strategy involving initial medical therapy. Recently a post hoc analysis of the ISCHEMIA trial has been published in JACC, whereby investigators assessed outcomes separately for invasive patients treated with PCI or CABG.

Patients without preceding primary outcome events were categorized as invasive-PCI or invasive-CABG from the time of revascularization. The study utilized the ISCHEMIA primary outcome, a composite measure of cardiovascular death, protocol-defined myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest.

Among patients who underwent invasive-CABG, primary outcome events were observed in 84 out of 512 (16.4%) individuals during a median follow-up of 2.85 years, with 57.1% occurring within 30 days after CABG. In contrast, among patients who underwent invasive-PCI, primary outcome events occurred in 147 out of 1,500 (9.8%) patients over a median follow-up of 2.94 years, with 21.1% occurring within 30 days after PCI. Comparatively, among the conservative (CON) group, 352 out of 2,591 patients (13.6%) experienced primary outcome events over a median follow-up of 3.2 years, with 6.3% occurring within 30 days of randomization. After adjusting for relevant factors, the risks of primary outcome events were found to be higher within 30 days following both CABG and PCI procedures, but lower thereafter.

The latest analysis of the ISCHEMIA trial reveals that among patients with chronic coronary artery disease, both PCI and CABG carry higher periprocedural risks but subsequently lower cardiovascular risks compared to a conservative approach. Procedural myocardial infarctions (MIs), particularly after CABG, were the primary early events following revascularization, while spontaneous MIs were the most common late events reduced by PCI or CABG compared to conservative management. The incidence and proportions of these events vary depending on their definitions, which could significantly influence a trial’s primary outcome.

The authors stated that this underscores the importance of carefully considering the definitions and clinical significance of individual events within composite outcomes when interpreting trial findings. While the elimination of procedural MI from composite outcomes in CABG and PCI trials is not recommended entirely, as certain procedural events may have prognostic relevance, further research is needed to refine the definition of procedural MI post-revascularization and determine whether criteria should be uniform or distinct for PCI and CABG procedures.

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Original article: Redfors B et al. J Am Coll Cardiol 2024;83:549–558


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