The ISCHEMIA trial (2019) compared initial invasive strategy versus conservative strategy in patients with stable coronary artery disease and moderate-to-severe ischemia on stress testing. Its key finding was:
- A Invasive strategy significantly reduced the primary endpoint of death or MI at 3.3 years
- B Invasive strategy reduced risk of spontaneous MI but not overall mortality versus optimal medical therapy
- C Invasive strategy improved quality of life but had higher procedural MI rates without benefit in hard endpoints ✓
- D Conservative strategy was superior in all pre-specified subgroups including diabetics
Correct answer: C. Invasive strategy improved quality of life but had higher procedural MI rates without benefit in hard endpoints
Explanation
The ISCHEMIA trial found no significant difference in the composite of death, MI, hospitalisation for unstable angina, heart failure, or resuscitated cardiac arrest between the invasive and conservative groups over median 3.3 years. The invasive arm had more early procedural MIs but fewer spontaneous MIs later. Quality of life (angina relief) was better with the invasive approach in symptomatic patients. This fundamentally changed the guidelines for managing stable CAD.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.