Heart Disease: Invasive Treatment is Not Necessarily Better

There have been some studies showing that in patients with stable heart disease caused by narrowing of the coronary arteries, stents and bypass surgery don’t necessarily improve mortality.  The following is the last salvo in that debate.  This is a summary from Physician’s First Watch

 

ISCHEMIA: Invasive Treatment Not Better Than Meds in Patients with Stable Ischemic Heart Disease

By Amy Orciari Herman

In patients with stable ischemic heart disease, invasive treatment appears no better than optimal medical therapy for preventing cardiovascular (CV) events, according to the international ISCHEMIA trial. The findings were presented on Saturday at the American Heart Association’s annual meeting in Philadelphia.

Nearly 5200 adults with stable ischemic heart disease and moderate-to-severe ischemia (usually diagnosed by stress imaging) were randomized to invasive or conservative management. In the invasive group, patients underwent cardiac catheterization followed by percutaneous coronary intervention (PCI) or coronary artery bypass grafting, when feasible; they also received optimal medical therapy. The conservative group received optimal medical therapy alone. Of note, patients with left main disease were excluded.

At 4 years, incidence of the primary endpoint — a composite of CV death, myocardial infarction (MI), resuscitated cardiac arrest, hospitalization for unstable angina, or heart failure — did not differ significantly between the invasive and conservative groups (13.3% and 15.5%, respectively). A major secondary endpoint comprising CV death or MI also did not differ significantly (11.7% and 13.9%).

Dr. Harlan Krumholz, editor-in-chief of NEJM Journal Watch Cardiology, offered his take: “The ISCHEMIA study is a lot to digest — and the results haven’t yet been published in a peer-reviewed journal. Yet, what seems clear is that patients with stable ischemic disease are safe with medical therapy, which is consistent with many other studies. A side question is whether stress myocardial perfusion studies are providing much value for these patients.”

Why We Chose This as Our Top Story

André Sofair, MD, MPH: Similar results have been described in other studies. I think that this is another case where less may be more for our patients. I think Dr. Krumholz’s comment is an important one — whether we should be performing stress tests on these patients is still an unanswered question.

William E. Chavey, MD, MS: As we digest the results of this trial, the take-home message for primary care may not be about who deserves PCI — but may be about the importance of ensuring that our patients get appropriate guideline-directed therapy.