ISCHEMIA trial: the endless story

Coronary artery disease (CAD) can cause angina, myocardial infarction, sudden death and heart failure. Its treatments include optimal medical therapy (OMT), surgical revascularization and percutaneous coronary intervention (PCI) revascularization.
This review dissects the results of two studies, COURAGE (2007) and ISCHEMIA (2020), which compared an invasive strategy (selective coronary angiography and PCI revascularization) to a non-invasive one (OMT alone) in patients with myocardial ischemia due to CAD. Authors found that both studies reported no benefit of PCI in terms of mortality and major adverse cardiac event (MACE) risk in patients with stable CAD, also known as chronic coronary syndrome. As such, percutaneous revascularization in patients with stable CAD does not seem to lead to any prognostic improvement compared to OMT alone.
In greater-risk patients, authors found that no differences emerged between invasive and non-invasive treatments regarding total mortality or myocardial infarction.
Take-home message: Results of COURAGE and ISCHEMIA studies confirm that invasive PCI revascularization in patients with stable CAD (i.e. CCS) does not improve prognosis compared to non-invasive optimal medical therapy alone. However, revascularization does indeed have a favourable impact in ‘spontaneous heart attacks’. The necessity and timing of the transition between non-invasive and invasive treatments for patients suffering from CAD is a challenge every cardiologist must undertake to engage in tailored patient-care.