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

Implications of the Myocardial Infarction Narrative in ISCHEMIA for Routine Cardiology Practice

The findings of ISCHEMIA placed in appropriate context with prior randomized trials demonstrate that patients with CCS with moderate-to-severe ischaemia due to obstructive CAD in whom left main CAD is excluded should be initiated on a robust medical regimen of anti-anginal therapies, disease-modifying therapies, risk factor treatment and lifestyle interventions, including smoking cessation, weight loss where indicated, and regular aerobic exercise. Since the ISCHEMIA quality-of-life analysis showed a reduction in angina with the invasive strategy, patients with persistent and unacceptable angina should be referred for invasive angiography and considered for revascularization. For patients with infrequent (i.e. monthly) angina, which characterized ~80% of ISCHEMIA patients, there would seem to be a much less compelling justification for revascularization, and cardiologists should no longer refer patients for revascularization solely based on the results of ischaemia testing.

In summary, interpretations of presumed revascularization benefit predicated on a reduction in spontaneous MI in ISCHEMIA that dismiss the consequences of periprocedural and late procedure-related MI may lead to fallacious conclusions that are neither balanced nor fact-based. Thus, caution and circumspection should guide both discussions with patients with CCS and any decision-making about the risks and benefits of revascularization, while emphasizing that OMT remains the preferred initial approach to management.