Interpreting Myocardial Infarction Analyses in ISCHEMIA

Separating Facts From Fallacy

Raffaele De Caterina; David L. Brown


Eur Heart J. 2021;42(31):2986-2989. 

In This Article

Relevant Background

Decades of accumulated dogma have suggested not just an association, but a causal relationship, between epicardial obstructive coronary artery stenoses, myocardial ischaemia, and adverse outcomes—including mortality and MI—thus leading to the prevalent belief that reduction of ischaemia by revascularization improves clinical outcomes. However, since 2003, a number of randomized controlled trials (RCTs)[2–4] and meta-analyses[5] have failed to demonstrate an interaction between ischaemia, revascularization, and mortality. However, in those studies, the extent and severity of ischaemia was not well characterized. ISCHEMIA was unique because it was the first RCT of an invasive strategy with state-of-the-art revascularization techniques plus optimal medical therapy (OMT) vs. OMT alone in patients with moderate-to-severe ischaemia. It also addressed other methodological weaknesses of prior studies, including randomization before delineating coronary anatomy, a goal of revascularization of all ischaemic areas (total ischaemic revascularization), and use of second-generation drug-eluting stents.