The ISCHEMIA trial randomized patients with stable coronary artery disease and moderate to severe ischemia on stress testing to an initial invasive strategy (angiography plus revascularization where feasible) versus an initial conservative strategy with optimal medical therapy. Its headline conclusion was:

• A An initial invasive strategy reduced death or myocardial infarction but not angina
• B An initial invasive strategy did not reduce death or myocardial infarction compared with optimal medical therapy, though it relieved angina better ✓
• C Conservative therapy reduced mortality, so angiography should be avoided in stable ischemic heart disease
• D Both strategies produced identical symptom relief, making revascularization redundant in every patient

Explanation

ISCHEMIA found that beginning with invasive management did not reduce death from cardiovascular causes, myocardial infarction or hospitalization for unstable angina compared with optimal medical therapy first, although the invasive arm produced greater and more durable relief of angina, especially in patients with more frequent baseline symptoms. This supports a symptom-guided approach rather than anatomy-driven revascularization in stable disease. It does not forbid angiography when symptoms are refractory or high-risk features exist.

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

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Written and medically reviewed by the StethoPrep medical team.