Virtual ACC 2020 | Relationship between Ischemia Severity and CAD

The ISCHEMIA trial enables countless sub-studies. Many of them have made part of the virtual ACC 2020, and among them you will find the present study. 

This analysis finds it is the anatomy — rather than ischemia — which predicts events. And even more interesting is the fact that revascularizing this particular anatomy will not change prognosis. 

Anatomical severity of CAD predicts risk of death and MI at 4 years. However, an invasive strategy compared against optimal medical treatment (OMT) offers no benefits, regardless ischemia or CAD severity. 

This analysis tells us the main study’s outcomes apply to the whole spectrum of severe ischemia and anatomy. 

Read also: Virtual ACC 2020 | Controversial Trial ISCHEMIA Finally in NEJM.

The more extended the disease, the greater the chance of MI or death. An invasive strategy will not make a significant difference in events rate vs. OMT.

This was true even for patients with multivessel disease or two-vessel disease and LAD compromise (left anterior descending artery). 

The idea that revascularization could have a particular benefit in patients with more severe disease has been among us since the COURAGE study and, in fact, it was the rationale behind the ISCHEMIA.

Read also: Virtual ACC 2020 | More data from ISCHEMIA: Women with More Symptoms but Less Ischemia.

The present analysis looks deeper than the general study into the relationship between ischemic burden, number of lesions and eventual benefit of an invasive strategy. 

Out of the total number of patients, 1261 presented obstructive CAD ≥70% in three vessels or ≥70% in two vessels but including the LAD; while other 1027 presented obstructions ≥70% in two vessels, or in three vessels ≥50%, or in the LAD ≥70%. All cardiologists will agree on the fact that these 2000+ patients really presented CAD. 

Using patients with no or mild ischemia as reference, there was no link between ischemia severity and mortality and only a modest link between patients with more severe ischemia and MI risk (p=0.04). On the contrary, patients with few anatomical lesions clearly presented lower mortality and risk of MI (p<0.001 for both).

Read also: Virtual ACC 202 | Vericiguat: New Hope in Chronic Cardiac Failure.

Across the ischemia spectrum and the anatomical severity spectrum revascularization had no benefit as regards primary end point of death or MI at 3.2-year follow-up.

Original Title: Relationships of ischemia severity and coronary artery disease extent with clinical outcomes in the ISCHEMIA trial.

Reference: Reynolds H et al. ACC 2020 virtual.

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