ESC 2020 | Revascularization Strategies: Ventricular Dysfunction Might Tilt the Scales

Patients included in the ISCHEMIA trial who had a history of cardiac failure or ventricular function deterioration will benefit from revascularization vs. optimal medical treatment. This is a pre-specified analysis of the paradigmatic ISCHEMIA trial.

The ISCHEMIA was published in March 2020 in NEJM and went somewhat unnoticed due to the COVID-19 pandemic. 

At the time, the ISCHEMIA-CKD also came out; it looked at a population of higher baseline risk (patients with chronic kidney disease) and also failed to show revascularization benefits. 

Now, from the ESC 2020, we receive information on another high risk subgroup: patients with cardiac failure or ventricular function deterioration. 

These findings suggest that stable patients with moderate to severe ischemia and evidence of mild ventricular function deterioration will benefit from a more invasive therapy such as revascularization (be it percutaneous or surgical). 

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

According to Dr. Renato Lopes, presenter and main author of this study, these results only generate hypothesis given the small number of patients with ventricular function deterioration included in the study. 

Of the 5129 patients included in the ISCHEMIA, only 4% had a history of cardiac failure and only 1.1% had required hospitalization because of it. Mean ventricular function of the global population was 60% vs 44% of this small subgroup of higher risk.

The combined end point occurred in 17.2% of patients undergoing revascularization vs. 29.3% of patients receiving the conservative therapy (p=0.055).

Read also: AHA 2019 | ISCHEMIA: The Invasive Approach (PCI or Surgery) Results Similar to Optimal Medical Treatment.

Revascularization type was split between PCI and CABG, depending on immediate risk and protection against future events at long term. 

These outcomes are on the same line of the STITCHES outcomes and call for further research. 

Original Title: Initial invasive versus conservative management for stable ischemic heart disease with a history of heart failure or left ventricular dysfunction: insights from the ISCHEMIA trial.

Reference: Lopes R, et al. Presentado en forma virtual en el congreso ESC 2020.

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