Outcomes According to Coronary Revascularization Modality in the ISCHEMIA Trial

Bjorn Redfors; Gregg W Stone; John H Alexander; Eric R Bates; Deepak L Bhatt; Giuseppe Biondi-Zoccai; Tulio Caldonazo; Michael Farkouh; Mohamed Rahouma; John Puskas; Sigrid Sandner; Mario F L Gaudino

doi:10.1016/j.jacc.2023.11.002

Outcomes According to Coronary Revascularization Modality in the ISCHEMIA Trial

J Am Coll Cardiol. 2024 Feb 6;83(5):549-558. doi: 10.1016/j.jacc.2023.11.002. Epub 2023 Nov 11.

Authors

Affiliations

¹ Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University, Gothenburg, Sweden; Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Gothenburg, Sweden; Department of Population Health Sciences, Weill Cornell Medicine, New York, New York, USA.
² Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
³ Division of Cardiology and the Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA.
⁴ Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA.
⁵ Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
⁶ Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy; Mediterranea Cardiocentro, Napoli, Italy.
⁷ Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University Jena, Germany; Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA.
⁸ Peter Munk Cardiac Centre and the Heart and Stroke Richard Lewar Centre, University of Toronto, Toronto, Ontario, Canada.
⁹ Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA.
¹⁰ Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai Cardiovascular Institute, New York, New York, USA; Department of Cardiovascular Surgery, Mount Sinai Heart at Mount Sinai Beth Israel, New York, New York, USA.
¹¹ Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA; Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria.
¹² Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA. Electronic address: mfg9004@med.cornell.edu.

PMID: 37956961
DOI: 10.1016/j.jacc.2023.11.002

Abstract

Background: In the ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial, the risk of ischemic events was similar in patients with stable coronary artery disease treated with an invasive (INV) strategy of angiography and percutaneous coronary intervention (PCI) or surgical (coronary artery bypass grafting [CABG]) coronary revascularization and a conservative (CON) strategy of initial medical therapy.

Objectives: The authors analyzed separately the outcomes of INV patients treated with PCI or CABG.

Methods: Patients without preceding primary outcome events were categorized as INV-PCI or INV-CABG from the time of revascularization. The ISCHEMIA primary outcome (composite of cardiovascular death, protocol-defined myocardial infarction or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest) was used.

Results: Among INV-CABG patients, primary outcome events occurred in 84 of 512 (16.4%) at a median follow-up of 2.85 years; 48 events (57.1%) occurred within 30 days after CABG, including 40 procedural MIs. Among INV-PCI patients, primary outcome events occurred in 147 of 1,500 (9.8%) at median follow-up of 2.94 years; 31 of which (21.1%) occurred within 30 days after PCI, including 24 procedural MIs. In comparison, 352 of 2,591 CON patients (13.6%) had primary outcome events at a median follow-up of 3.2 years, 22 of which (6.3%) occurred within 30 days of randomization. The adjusted primary outcome risks were higher after both CABG and PCI within 30 days (HR: 16.25 [95% CI: 11.44-23.07] and HR: 2.99 [95% CI: 1.97-4.53]) and lower thereafter (0.63 [95% CI: 0.44-0.89] and 0.66 [95% CI: 0.53-0.82]).

Conclusions: In ISCHEMIA, early revascularization by PCI and CABG was associated with higher early risks and lower long-term risks of cardiovascular events compared with CON. The early risk was greatest after CABG, owing to protocol-defined procedural MIs.

Keywords: CABG; Coronary arterial bypass grafting; PCI; chronic coronary artery disease; optimal medical therapy; percutaneous coronary intervention; revascularization.

MeSH terms

Coronary Artery Bypass / adverse effects
Coronary Artery Disease* / therapy
Humans
Myocardial Infarction* / etiology
Percutaneous Coronary Intervention* / adverse effects
Treatment Outcome