Author + information
- Received July 3, 2015
- Revision received September 10, 2015
- Accepted September 22, 2015
- Published online January 5, 2016.
- Gregg W. Stone, MD∗∗ (, )
- Judith S. Hochman, MD†,
- David O. Williams, MD‡,
- William E. Boden, MD§,
- T. Bruce Ferguson Jr., MD‖,
- Robert A. Harrington, MD¶ and
- David J. Maron, MD¶
- ∗Department of Medicine, Columbia University Medical Center, New York Presbyterian Hospital and the Cardiovascular Research Foundation, New York, New York
- †Department of Medicine, Cardiovascular Clinical Research Center, New York University School of Medicine, New York, New York
- ‡Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- §Department of Medicine, Samuel S. Stratton VA Medical Center, Albany Medical Center and Albany Medical College, Albany, New York
- ‖Department of Cardiovascular Sciences, East Carolina Heart Institute, East Carolina University, Greenville, North Carolina
- ¶Department of Medicine, Stanford University School of Medicine, Stanford, California
- ↵∗Reprint requests and correspondence:
Dr. Gregg W. Stone, Columbia University Medical Center, Cardiovascular Research Foundation, 111 East 59th Street, 11th Floor, New York, New York 10022.
All patients with stable ischemic heart disease (SIHD) should be managed with guideline-directed medical therapy (GDMT), which reduces progression of atherosclerosis and prevents coronary thrombosis. Revascularization is also indicated in patients with SIHD and progressive or refractory symptoms, despite medical management. Whether a strategy of routine revascularization (with percutaneous coronary intervention or coronary artery bypass graft surgery as appropriate) plus GDMT reduces rates of death or myocardial infarction, or improves quality of life compared to an initial approach of GDMT alone in patients with substantial ischemia is uncertain. Opinions run strongly on both sides, and evidence may be used to support either approach. Careful review of the data demonstrates the limitations of our current knowledge, resulting in a state of community equipoise. The ongoing ISCHEMIA trial (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) is being performed to determine the optimal approach to managing patients with SIHD, moderate-to-severe ischemia, and symptoms that can be controlled medically. (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches [ISCHEMIA]; NCT01471522)
- angina pectoris
- coronary artery bypass
- coronary artery disease
- guideline-directed medical therapy
- percutaneous coronary intervention
The ISCHEMIA trial, which is discussed in this article, is supported by National Heart, Lung, and Blood Institute grant U01HL105907, in-kind donations from Abbott Vascular; Medtronic, Inc., St. Jude Medical, Inc., Volcano Corporation, Arbor Pharmaceuticals, LLC, AstraZeneca Pharmaceuticals, LP, Merck Sharp & Dohme Corp., and Omron Healthcare, Inc.; and by financial donations from Arbor Pharmaceuticals LLC and AstraZeneca Pharmaceuticals LP. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Heart, Lung, and Blood Institute or the National Institutes of Health. Dr. Stone is a consultant for Reva Corporation; and has received NIH grant support for the ISCHEMIA trial. Drs. Hochman, Boden, and Maron have received NIH grant support for the ISCHEMIA trial. Dr. Harrington has received consultant fees or honoraria from Amgen Inc., Adverse Events, Daiichi-Lilly, GILEAD Sciences, Janssen, Medtronic, Merck & Co., Novartis, The Medicines Company, Vida Health, Vox Media, and WebMD; has received research grants from AstraZeneca, Bristol-Myers Squibb, CSL Behring, GlaxoSmithKline, Merck & Co., Portola, Regado, Sanofi, and The Medicines Company; has equity in Element Science and MyoKardia; and is an officer, director, or trustee of Evidint and Scanadu. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received July 3, 2015.
- Revision received September 10, 2015.
- Accepted September 22, 2015.
- American College of Cardiology Foundation