Asymptomatic Coronary Artery Disease, Silent Ischemia: A Cardiologist’s Headache

We need more evidence to guide us in the management of silent ischemia. Confirmed asymptomatic coronary artery disease is a problem for cardiologists, who lack enough evidence to guide a risk-benefit assessment that justifies revascularization. Revascularizing the outcome of a functional assessment may reduce the rates of death and infarction, or it may just be an appeasing placebo for both patient and primary care physician (without taking into account the risks inherent to the procedure).

The treatment of asymptomatic stable ischemic heart disease patients varies widely across centers, according to this new study recently published in J Am Coll Cardiol Intv., indicating that there is a need for randomized data to better guide strategic decision-making regarding this special population.

Overall, revascularization with surgery or angioplasty was slightly more frequent than medical therapy alone, but there was a more than twofold difference regarding the strategy across centers.

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Despite the wide dispersion, there was a consistent relationship between use of revascularization and lower risks of death (hazard ratio [HR]: 0.81; 95% confidence interval [CI]: 0.69-0.96) and infarction (HR: 0.58; 95% CI: 0.46-0.73).

These findings can only generate hypothesis due to a lack of randomized evidence. Given the low rate of events, this population should include a large number of patients and a prolonged follow-up. All of this means that the required evidence will not see the light of day for some time.

The ISCHEMIA trial (which is expected to be published late this year or in early 2020) will contribute some insights into the treatment of asymptomatic patients.

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In the meantime, the suggestion that revascularization reduces the risk of death and of infarction in this population should be interpreted with caution due to the possible influence of multiple confounding variables on this work.

The largest trials comparing revascularization (any method) with conservative medical therapy, such as COURAGE or BARI 2D, have not included enough asymptomatic patients so as to derive conclusions.

While revascularization in asymptomatic patients with extensive ischemic areas or high-risk anatomies can be considered appropriate, for all other patients all we have is speculation.

Original title: Variation in Revascularization Practice and Outcomes in Asymptomatic Stable Ischemic Heart Disease.

Reference: Czarnecki A et al. J Am Coll Cardiol Intv. 2019; Epub ahead of print.

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