The main studies carried out on patients with chronic coronary syndromes (CCS), such as the MASS II, COURAGE, BARI 2D and FAME-2, failed to show benefits in terms of mortality with the invasive approach.
The ISCHEMIA, a large randomized study including patients with moderate to severe ischemia, with without left main disease and with acceptable or no angina, also failed to show benefits as to reducing the risk of ischemic events when opting for an invasive strategy (INV) vs. a conservative strategy (CON) with medical treatment at mean 3.2 years.
Of the 2054 INV patients, 74.1% received PCI, while 25.8% opted for CABG. An ad-hoc analysis of the ISCHEMIA compared events related to INV-PCI and INV CABG, taking into account revascularization modality was not random. The aim of this study was to assess the risk of early and late events associated to each strategy. Primary end point was a composite of cardiovascular death, myocardial infarction (MI), hospitalization for unstable angina, cardiac failure or resuscitated cardiac arrest.
The analysis looked at INV-MED (from randomization to revascularization), INV-PCI and INV-CABG strategy outcomes, and compared them to the CON strategy outcomes. They analyzed events at 30 days (early) and beyond 30 days (late).
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Mean time from randomization to revascularization was 22 days for PCI and 44 days for CABG. Of the 512 INV-CABG patients, 16.4% experienced primary end outcomes at mean 2.85 years, with 57.1% of these events occurring within 30 days (83.3% were MI). Of the 1500 INV-PCI, 9.8% presented primary end outcomes at mean 2.94 years, with 21.1% early occurrence (77.4% of these early events were MI). When comparing against the 2591 CON patients, 13.6% presented primary end outcomes, with an early occurrence of 6.3%.
Cumulative primary end point incidence at long term in MED, PCI and CABG was similar at secondary analysis. We should note that periprocedural MI was the only event in 40.5% of INV-CABG cases and in 16.3% of INV-PCI (separately). INV-PCI and INV-CABG were associated with greater early risk and lower late risk vs. CON.
Conclusions
Revascularization with CABG and PCI in INV patients was associated with higher incidence of cardiovascular events, especially periprocedural MI. However, this event incidence saw a reduction at long term vs. the conservative strategy. We should not overlook the non-random nature of these outcomes, especially considering that patients undergoing CABG had more severe CAD, which leads to higher adverse outcomes.
Dr. Omar Tupayachi.
Member of the Editorial Board of SOLACI.org.
Original Title: Outcomes According to Coronary Revascularization Modality in the ISCHEMIA Trial.
Reference: Redfors, B, Stone, G, Alexander, J. et al. Outcomes According to Coronary Revascularization Modality in the ISCHEMIA Trial. J Am Coll Cardiol. 2024 Feb, 83 (5) 549–558.
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