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Ischemia Trial: Does the Cardiology Community Need to Pivot or Continue Current Practices?
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...
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| Published in: | Current cardiology reports 2022-08, Vol.24 (8), p.1059-1068 |
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| container_title | Current cardiology reports |
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| creator | Jafary, Fahim H. Jafary, Ali H. |
| description | 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) |
| doi_str_mv | 10.1007/s11886-022-01725-1 |
| format | article |
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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.</description><identifier>ISSN: 1523-3782</identifier><identifier>ISSN: 1534-3170</identifier><identifier>EISSN: 1534-3170</identifier><identifier>DOI: 10.1007/s11886-022-01725-1</identifier><identifier>PMID: 35653055</identifier><language>eng</language><publisher>New York: Springer US</publisher><subject>Angina Pectoris ; Cardiology ; Coronary Artery Disease - therapy ; Humans ; Medicine ; Medicine & Public Health ; Myocardial Infarction - therapy ; Myocardial Ischemia - therapy ; Public Health Policy (SS Virani and D Mahtta ; Public Health Policy (SS Virani and D Mahtta, Section Editors) ; Section Editors ; Topical Collection on Public Health Policy ; Treatment Outcome</subject><ispartof>Current cardiology reports, 2022-08, Vol.24 (8), p.1059-1068</ispartof><rights>The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2022</rights><rights>2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c376t-a342b6602b568a9bd77a86d95b422ca3899333dcd8dcee8150eace7e9e3a95cb3</citedby><cites>FETCH-LOGICAL-c376t-a342b6602b568a9bd77a86d95b422ca3899333dcd8dcee8150eace7e9e3a95cb3</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><link.rule.ids>230,314,776,780,881,27901,27902</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/35653055$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Jafary, Fahim H.</creatorcontrib><creatorcontrib>Jafary, Ali H.</creatorcontrib><title>Ischemia Trial: Does the Cardiology Community Need to Pivot or Continue Current Practices?</title><title>Current cardiology reports</title><addtitle>Curr Cardiol Rep</addtitle><addtitle>Curr Cardiol Rep</addtitle><description>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.</description><subject>Angina Pectoris</subject><subject>Cardiology</subject><subject>Coronary Artery Disease - therapy</subject><subject>Humans</subject><subject>Medicine</subject><subject>Medicine & Public Health</subject><subject>Myocardial Infarction - therapy</subject><subject>Myocardial Ischemia - therapy</subject><subject>Public Health Policy (SS Virani and D Mahtta</subject><subject>Public Health Policy (SS Virani and D Mahtta, Section Editors)</subject><subject>Section Editors</subject><subject>Topical Collection on Public Health Policy</subject><subject>Treatment Outcome</subject><issn>1523-3782</issn><issn>1534-3170</issn><issn>1534-3170</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2022</creationdate><recordtype>article</recordtype><recordid>eNp9kTtP5DAUhS0E4v0HKJBLmix-xHZCAULDwiKhXQq22cZynMuMUWKD7SDNv8cwgJaG6lo63znXugehA0p-UELUcaK0aWRFGKsIVUxUdA1tU8HrilNF1l_fjFdcNWwL7aT0QAgrtnoTbXEhBSdCbKN_18kuYHQG30VnhhN8ESDhvAA8M7F3YQjzJZ6FcZy8y0v8G6DHOeBb9xwyDrFIPjs_FXyKEXzGt9HY7Cyksz20cW-GBPvvcxf9vfx5N_tV3fy5up6d31SWK5krw2vWSUlYJ2Rj2q5XyjSyb0VXM2YNb9qWc97bvuktQEMFAWNBQQvctMJ2fBedrnIfp26EAvkczaAfoxtNXOpgnP6qeLfQ8_CsWyrLBVkJOHoPiOFpgpT16JKFYTAewpQ0k4opUislC8pWqI0hpQj3n2so0a-l6FUpupSi30rRtJgO___gp-WjhQLwFZCK5OcQ9UOYoi9H-y72BeTYmTY</recordid><startdate>20220801</startdate><enddate>20220801</enddate><creator>Jafary, Fahim H.</creator><creator>Jafary, Ali H.</creator><general>Springer US</general><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>7X8</scope><scope>5PM</scope></search><sort><creationdate>20220801</creationdate><title>Ischemia Trial: Does the Cardiology Community Need to Pivot or Continue Current Practices?</title><author>Jafary, Fahim H. ; Jafary, Ali H.</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c376t-a342b6602b568a9bd77a86d95b422ca3899333dcd8dcee8150eace7e9e3a95cb3</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2022</creationdate><topic>Angina Pectoris</topic><topic>Cardiology</topic><topic>Coronary Artery Disease - therapy</topic><topic>Humans</topic><topic>Medicine</topic><topic>Medicine & Public Health</topic><topic>Myocardial Infarction - therapy</topic><topic>Myocardial Ischemia - therapy</topic><topic>Public Health Policy (SS Virani and D Mahtta</topic><topic>Public Health Policy (SS Virani and D Mahtta, Section Editors)</topic><topic>Section Editors</topic><topic>Topical Collection on Public Health Policy</topic><topic>Treatment Outcome</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Jafary, Fahim H.</creatorcontrib><creatorcontrib>Jafary, Ali H.</creatorcontrib><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>MEDLINE - Academic</collection><collection>PubMed Central (Full Participant titles)</collection><jtitle>Current cardiology reports</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Jafary, Fahim H.</au><au>Jafary, Ali H.</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Ischemia Trial: Does the Cardiology Community Need to Pivot or Continue Current Practices?</atitle><jtitle>Current cardiology reports</jtitle><stitle>Curr Cardiol Rep</stitle><addtitle>Curr Cardiol Rep</addtitle><date>2022-08-01</date><risdate>2022</risdate><volume>24</volume><issue>8</issue><spage>1059</spage><epage>1068</epage><pages>1059-1068</pages><issn>1523-3782</issn><issn>1534-3170</issn><eissn>1534-3170</eissn><abstract>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.</abstract><cop>New York</cop><pub>Springer US</pub><pmid>35653055</pmid><doi>10.1007/s11886-022-01725-1</doi><tpages>10</tpages><oa>free_for_read</oa></addata></record> |
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| issn | 1523-3782 1534-3170 1534-3170 |
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| subjects | Angina Pectoris Cardiology Coronary Artery Disease - therapy Humans Medicine Medicine & Public Health Myocardial Infarction - therapy Myocardial Ischemia - therapy Public Health Policy (SS Virani and D Mahtta Public Health Policy (SS Virani and D Mahtta, Section Editors) Section Editors Topical Collection on Public Health Policy Treatment Outcome |
| title | Ischemia Trial: Does the Cardiology Community Need to Pivot or Continue Current Practices? |
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