Myocardial Ischemia in the Management of Chronic Coronary Artery Disease: Past and Present

Stress-induced myocardial ischemia has long been considered important in the management of chronic coronary artery disease (CAD). The recently completed ISCHEMIA trial was designed to test the hypothesis that revascularization would improve outcomes in patients with moderate-severe ischemia on stress testing.
However, the ISCHEMIA trial presented negative results, notably due to long term population decline in CAD coupled with abnormal stress tests. Both factors are attributed to the emerging importance of optimal medical therapy (OMT) in chronic CAD management.
The author contends that stress imaging modalities, which are focused on exercise capacity, are still useful in identifying angina. Coupling stress imaging with quantitative positron emission tomography perfusion studies may further increase the efficiency of microvascular angina diagnosis. This may better the diagnosis and management of suspected CAD.
Take-home message: The author argues that the negative results of the ISCHEMIA trial should not be attributed to a failure of revascularization practices, but rather to the success of OMT. Focusing on consistency and adherence to OMT in patient care could greatly improve chronic CAD management. Coupling OMT with percutaneous coronary intervention (PCI) to increase efficiency of CAD treatment requires exploration.