Editorial
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Cardiol. Aug 26, 2021; 13(8): 237-242
Published online Aug 26, 2021. doi: 10.4330/wjc.v13.i8.237
ISCHEMIA trial: How to apply the results to clinical practice
Rafael Vidal-Perez, Alberto Bouzas-Mosquera, Jesus Peteiro, Jose Manuel Vazquez-Rodriguez
Rafael Vidal-Perez, Alberto Bouzas-Mosquera, Jesus Peteiro, Servicio de Cardiología, Unidad de Imagen y Función Cardíaca, Complexo Hospitalario Universitario A Coruña (CHUAC) Centro de Investigación Biomédica en Red (CIBERCV)-Instituto de Salud Carlos III, A Coruña 15006, Spain
Jose Manuel Vazquez-Rodriguez, Servicio de Cardiología, Complexo Hospitalario Universitario A Coruña, A Coruña 15006, Spain
Author contributions: Vidal-Perez R contributed to conception and design of the editorial and edited and wrote the paper; Bouzas-Mosquera A, Peteiro J, and Vazquez-Rodriguez JM contributed to the critical revision and editing of the paper.
Conflict-of-interest statement: The authors declare that there are no conflicts of interest.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Rafael Vidal-Perez, MD, PhD, Staff Physician, Servicio de Cardiología, Unidad de Imagen y Función Cardíaca, Complexo Hospitalario Universitario A Coruña (CHUAC) Centro de Investigación Biomédica en Red (CIBERCV)-Instituto de Salud Carlos III, As Xubias de Arriba - 84, A Coruña 15006, Spain. rafavidal@hotmail.com
Received: April 15, 2021
Peer-review started: April 15, 2021
First decision: May 13, 2021
Revised: May 27, 2021
Accepted: July 9, 2021
Article in press: July 9, 2021
Published online: August 26, 2021
Processing time: 130 Days and 5.3 Hours
Abstract

During the last years two questions have been continuously asked in chronic coronary syndromes: (1) Do revascularization procedures (coronary artery bypass grafting or percutaneous coronary intervention) really improve symptoms of angina? and (2) Do these techniques improve outcomes, i.e. do they prevent new myocardial infarction events and cardiovascular death? Therefore, there was a need for a large definitive trial. This study was the ISCHEMIA trial, a large, multicentric trial sponsored by the National Heart, Lung, and Blood Institute. The main trial compared coronary revascularization and optimal medical treatment (OMT) vs OMT alone in 5179 patients enrolled after a stress test. During a median 3.2-year follow-up, 318 primary outcome events occurred; the adjusted hazard ratio for the invasive strategy as compared with the conservative strategy was 0.93 (95% confidence interval 0.80-1.08, P = 0.34). The ISCHEMIA trial deeply disrupted many of our prior attitudes regarding management strategies for patients with stable coronary artery disease. The findings underscore the benefits of disease-modifying OMT for stable coronary artery disease patients. The main purposes of ischemia assessment before this trial were: Diagnostic purposes, assessment of outcome, and adding to decision-making processes. Obviously, this changed after the trial results. The results of ISCHEMIA might challenge the current diagnostic approach for stable angina patients recommended in the last European Society of Cardiology guidelines on chronic coronary disease that were based on studies published before the ISCHEMIA trial. In this editorial we propose our approach based on the ISCHEMIA study and the pretest probability for a positive test in patients with chronic coronary syndromes.

Keywords: Stable angina; Chronic coronary syndrome; ISCHEMIA; Stress testing; Therapy; Diagnosis

Core Tip: During the last years two questions have been continuously asked in chronic coronary syndromes: Do revascularization procedures (coronary artery bypass grafting or percutaneous coronary intervention) really improve symptoms of angina? Do these techniques improve outcomes, i.e. do they prevent new myocardial infarction events and cardiovascular death? The results of ISCHEMIA might challenge the current diagnostic approach for stable angina patients recommended in the last European Society of Cardiology guidelines on chronic coronary disease that were based on studies published before the ISCHEMIA trial. In this editorial we propose our approach based on the ISCHEMIA study and the pretest probability for a positive test in patients with chronic coronary syndromes.