In the ISCHEMIA trial, which key finding challenged the traditional approach to stable ischemic heart disease with significant ischemia on stress testing?

• A PCI reduced all-cause mortality compared to medical therapy at 4 years
• B Routine invasive strategy (PCI/CABG) did not reduce cardiovascular death or MI over optimal medical therapy ✓
• C CABG was superior to PCI for single-vessel disease with moderate ischemia
• D Optimal medical therapy alone increased cardiovascular events in those with severe ischemia

Explanation

The ISCHEMIA trial (2020) enrolled 5,179 patients with stable CAD and moderate-to-severe ischemia. After a median 3.2 years, routine invasive strategy did not reduce the primary endpoint (cardiovascular death, nonfatal MI, hospitalisation for unstable angina, heart failure, or resuscitated cardiac arrest) compared to conservative medical management. This landmark finding challenged the practice of routinely revascularising stable ischemic disease based solely on ischemia burden.

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

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