"Invasive Strategy vs. Conservative Strategy in Stable Coronary Disease and Moderate or Severe Ischemia".The New England Journal of Medicine. 2020.

Clinical Question

Does an invasive strategy improve clinical outcomes compared to a conservative strategy in patients with stable coronary disease and moderate or severe ischemia?

Bottom Line

Among patients with stable coronary disease and moderate or severe ischemia, an initial invasive strategy did not reduce the risk of ischemic cardiovascular events or death from any cause over a median of 3.2 years compared to a conservative strategy.

Major Points

Guidelines

Not provided; the study assessed medical therapy compared to medical therapy plus revascularization in stable coronary disease with ischemia.

Design

Multicenter, randomized, controlled trial with 5179 patients randomized to either an invasive strategy or conservative strategy.

Population

Patients with stable coronary disease and moderate or severe ischemia on stress testing. Key exclusions included recent acute coronary syndrome, left main coronary artery disease, ejection fraction <35%, class III/IV heart failure, and severe symptoms despite medical therapy.

Interventions

Invasive strategy (n=2588): medical therapy, angiography, and revascularization.
Conservative strategy (n=2591): medical therapy alone, with angiography reserved for medical therapy failure.

Outcomes

Primary Outcome:
- Composite of death from cardiovascular causes, myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest.
Secondary Outcomes:
- Composite of death from cardiovascular causes or myocardial infarction.
- Quality of life related to angina.

Criticisms

- Reduced power due to lower sample size and less than expected event rates.
- Median follow-up of 3.2 years is relatively short.
- Findings sensitive to the definition of myocardial infarction used.
- Outcomes do not necessarily apply to patients with acute coronary syndromes, significant left main coronary artery disease, low ejection fraction, class III or IV heart failure, or those highly symptomatic on medical therapy.

Funding

Supported by grants from the National Heart, Lung, and Blood Institute, Arbor Pharmaceuticals, AstraZeneca Pharmaceuticals, and others.

Further Reading

- Not provided.