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VIEWPOINT
Year : 2020  |  Volume : 21  |  Issue : 1  |  Page : 31  

After ischemia trial, what is the role of ischemia detection on noninvasive testing?


Department of Cardiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar

Date of Submission10-Dec-2019
Date of Acceptance10-Dec-2019
Date of Web Publication23-Jan-2020

Correspondence Address:
Dr. Abdul Rahman Arabi
Department of Cardiology, Heart Hospital, Hamad Medical Corporation, P. O. Box 3050, Doha
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/HEARTVIEWS.HEARTVIEWS_139_19

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Keywords: Coronary artery disease, guideline-directed medical therapy, percutaneous coronary intervention, stress testing


How to cite this article:
Arabi AR, Alqahtani A, Alsuwaidi J. After ischemia trial, what is the role of ischemia detection on noninvasive testing?. Heart Views 2020;21:31

How to cite this URL:
Arabi AR, Alqahtani A, Alsuwaidi J. After ischemia trial, what is the role of ischemia detection on noninvasive testing?. Heart Views [serial online] 2020 [cited 2020 Feb 28];21:31. Available from: http://www.heartviews.org/text.asp?2020/21/1/31/276533



Last November the results of ischemia trial were presented in the American Heart Association scientific meeting in Philadelphia. The study randomized more than 5000 patients with moderate or severe ischemia to optimal medical therapy (OMT) alone versus OMT plus optimal revascularization. After an average of 4 years of follow-up, there was no significant difference in primary outcomes (cardiovascular death, myocardial infarction, hospitalization for unstable angina, heart failure, or cardiac arrest). The study concluded that OMT alone is a safe initial treatment strategy in patients with symptomatic stable ischemic heart disease (SIHD) even in the presence of moderate to severe ischemia.

The results raise the question: What is the rule of noninvasive risk stratification in patients with SIHD if they all do well with medical therapy even in the presence of severe ischemia? Should we place all patients with typical angina on OMT (without risk stratification) and go straight to invasive assessment and revascularization when medical therapy alone fails? We cannot draw this conclusion from the ischemia trial for the following reasons:

  • There is always the possibility of selection bias: Patients with very severe ischemia on stress test are less likely to be considered for the study participation by their treating physicians and this study may not be applicable to them
  • Coronary computed tomography angiogram was performed in 73% of the study participants which further excluded a subgroup of very high-risk patients (434 patients were excluded because of significant left main disease)
  • The invasive group had higher events rate during the first 2 years of follow-up (1.9% absolute difference is mainly driven by periprocedural myocardial infarction), while in the past 2 years, the conservative group had a higher events rate (2.2% absolute difference, mainly driven by spontaneous myocardial infarction). It will be interesting to see if the curve will diverge more on longer follow-up
  • The study is not applicable to patients with acute coronary syndrome who represent almost 90% of 4500 patients who undergo coronary angiogram in our catheterization laboratory annually.


The results of ischemia should be interpreted with caution and it may not be applicable to patients with very high-risk findings on noninvasive functional or anatomical tests.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.






 

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