The ISCHEMIA trial (2020) challenged routine invasive strategy in stable ischemic heart disease. Which conclusion was demonstrated in patients with moderate-to-severe ischemia on non-invasive testing?

• A Routine invasive strategy (PCI/CABG) reduced all-cause mortality vs. optimal medical therapy alone
• B CABG was superior to PCI for reduction of myocardial infarction
• C Invasive strategy reduced stroke risk significantly in all subgroups
• D Optimal medical therapy was non-inferior to routine early invasive strategy for the primary composite endpoint ✓

Explanation

The ISCHEMIA trial enrolled over 5,000 patients with stable ischemic heart disease and moderate-to-severe ischemia and found that an initial conservative strategy with optimal medical therapy was non-inferior to a routine invasive approach for the primary composite endpoint of cardiovascular death, MI, resuscitated cardiac arrest, hospitalization for unstable angina, or heart failure at 3.2 years median follow-up. The invasive strategy had early risk of procedure-related MI but later benefit in spontaneous MI reduction, resulting in overlapping curves. This trial reshaped guidelines favoring medicine-first in stable IHD.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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