Invasive does not best a conservative approach for stable CAD

  • Maron DJ & al.
  • N Engl J Med
  • 30.03.2020

  • von Emily Willingham, PhD
  • Clinical Essentials
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Takeaway

  • For stable coronary artery disease (CAD), a conservative approach does not increase risk for ischemic events or mortality compared with an initial invasive strategy.

Why this matters

  • These results from the ISCHEMIA trial might ease concerns about postponing “elective” procedures as centers make space for treating COVID-19 cases.

Key results

  • 3.2-year median follow-up.
  • Early outcomes were 5.3% cumulative event rate with invasive treatment vs 3.4% with conservative (difference, 1.9 [95% CI, 0.8-3.0] percentage points).
  • At 5 years, these rates were 16.4% vs 18.2% (difference, −1.8 [95% CI, −4.7 to 1.0] percentage points).
  • An analysis adjusting for the definition of myocardial infarction found even more similar mortality: 145 with an invasive strategy vs 144 with a conservative approach (HR, 1.05; 95% CI, 0.83-1.32).
  • Invasive revascularization approaches (79%) were percutaneous coronary intervention (74%) and coronary artery bypass graft (26%).
  • 34% who initiated with conservative treatment shifted to invasive before the primary outcome event.
  • No evidence of difference in event-free time between groups.

Study design

  • 5179 patients (320 sites, 37 countries) were randomly allocated to initial invasive or conservative treatment (medical therapy alone), July 26, 2012 through January 31, 2018.
  • Primary outcome: composite of cardiovascular events/death.
  • Funding: National Heart, Lung, and Blood Institute; Arbor Pharmaceuticals; AstraZeneca Pharmaceuticals; others.

Limitations

  • Event rates beyond “modest” median follow-up not known.