Is There Still a Place for Revascularisation in the Management of Stable Coronary Artery Disease Following the ISCHEMIA Trial?

The ISCHEMIA trial (International study of comparative health effectiveness with medical and invasive approaches; ClinicalTrials.gov Identifier: NCT01471522) has informed practice in patients with stable angina and confirms what other less definitive data have taught us, that in the absence of severe symptoms, significant left main disease or significant left ventricular dysfunction, there is no prognostic benefit of an early invasive/revascularisation strategy with optimal medical therapy (OMT) over OMT alone. Like all quality randomised trials, it has nuances: the invasive treatment group had much better relief of angina than the OMT alone group, and the rate of spontaneous myocardial infarction (MI) in follow-up was lower in the invasive group, although only after a prevalence of periprocedural MI. The clinical outcome consequence of the MI data, if indeed there is one, will only become clear at later follow-up. OMT is a powerful treatment, and reflex revascularisation in patients with little or no angina is not.