Lessons learned from MPI and physiologic testing in randomized trials of stable ischemic heart disease: COURAGE, BARI 2D, FAME, and ISCHEMIA

• Published in: Journal of nuclear cardiology 2013-12, Vol.20 (6), p.969-975
• Main Authors: Phillips, Lawrence M., Hachamovitch, Rory, Berman, Daniel S., Iskandrian, Ami E., Min, James K., Picard, Michael H., Kwong, Raymond Y., Friedrich, Matthias G., Scherrer-Crosbie, Marielle, Hayes, Sean W., Sharir, Tali, Gosselin, Gilbert, Mazzanti, Marco, Senior, Roxy, Beanlands, Rob, Smanio, Paola, Goyal, Abhi, Al-Mallah, Mouaz, Reynolds, Harmony, Stone, Gregg W., Maron, David J., Shaw, Leslee J.
• Format: Article
• Language: English
• Subjects: Cardiology; clinical trials; coronary artery disease; Fractional Flow Reserve, Myocardial; Humans; Imaging; ischemia; Medicine; Medicine & Public Health; Myocardial Ischemia - physiopathology; Myocardial Ischemia - surgery; Myocardial Perfusion Imaging; Myocardial Revascularization; Nuclear Medicine; Perspective; Practice Guidelines as Topic; Radiology; Randomized Controlled Trials as Topic; Treatment Outcome
• ISSN: 1071-3581; 1532-6551
• DOI: 10.1007/s12350-013-9773-4

There is a preponderance of evidence that, in the setting of an acute coronary syndrome, an invasive approach using coronary revascularization has a morbidity and mortality benefit. However, recent stable ischemic heart disease (SIHD) randomized clinical trials testing whether the addition of coronary revascularization to guideline-directed medical therapy (GDMT) reduces death or major cardiovascular events have been negative. Based on the evidence from these trials, the primary role of GDMT as a front line medical management approach has been clearly defined in the recent SIHD clinical practice guideline; the role of prompt revascularization is less precisely defined. Based on data from observational studies, it has been hypothesized that there is a level of ischemia above which a revascularization strategy might result in benefit regarding cardiovascular events. However, eligibility for recent negative trials in SIHD has mandated at most minimal standards for ischemia. An ongoing randomized trial evaluating the effectiveness of randomization of patients to coronary angiography and revascularization as compared to no coronary angiography and GDMT in patients with moderate-severe ischemia will formally test this hypothesis. The current review will highlight the available evidence including a review of the published and ongoing SIHD trials.