A patient with chronic stable angina has an FFR of 0.79 across a 65% stenosis in the LAD on invasive coronary angiography. Optimal medical therapy (statin, beta-blocker, aspirin, ranolazine) has been maximised. What does the ISCHEMIA trial indicate about the next best step?
- A An initial conservative strategy with OMT is non-inferior to routine invasive strategy for major adverse cardiovascular events in stable ischaemic heart disease ✓
- B PCI is mandatory as FFR < 0.80 confers significant survival benefit over OMT
- C CABG is preferred over PCI in single-vessel disease with FFR-positive ischaemia
- D Coronary angiography should be repeated with IVUS to reassess plaque burden before deciding
Explanation
The ISCHEMIA trial (NEJM 2020) enrolled 5179 stable CAD patients with moderate-to-severe ischaemia and showed that an initial invasive strategy (PCI/CABG) was not superior to OMT alone for the primary endpoint of cardiovascular death, MI, hospitalisation for unstable angina, HF, or resuscitated cardiac arrest at median 3.2-year follow-up. Importantly, the invasive strategy did improve angina-related quality of life. Therefore, stable angina with preserved EF does not mandate revascularisation for prognostic benefit; the decision should be guided by symptom burden and patient preference.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.