International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) trial and the appropriateness of revascularization

The recently published ISCHEMIA trial which is a prospective randomized multi-centre trial has concluded that there was no evidence that an initial invasive strategy of revascularisation in patients with stable angina reduced the risk of ischaemic cardiovascular events or death from any cause. The trial has confirmed that patients with stable angina do not greatly benefit from revascularisation and optimal medical treatment (OMT) is an acceptable alternative. The trial has also confirmed that in patients with stable angina and end-stage renal impairment, OMT is once again an equally effective initial strategy. While the ISCHEMIA trial is one of the most rigorously and meticulously conducted trial, exclusion of symptomatic patients, recruitment of patients who are not known to derive significant benefit from revascularisation and those who were at low risk of clinical events, along with a short follow-up period, may all have contributed to the lack of difference seen between the groups. The fact that the ISCHEMIA trial does not represent the entire cohort of real-life patients requiring revascularisation should be borne in mind, and care should be taken in extrapolating these results to the wider group of patients requiring revascularisation for coronary artery disease.