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Initial invasive or conservative strategy for stable coronary disease

One-paragraph summary

ISCHEMIA randomized 5,179 stable patients with moderate or severe ischemia to an initial invasive strategy plus medical therapy or an initial conservative strategy with angiography reserved for failure. At 5 years, the primary composite was estimated at 16.4% versus 18.2%; confidence intervals included no difference, and deaths were 145 versus 144 (Maron 2020, PMID 32227755).

Key findings

  • Selecting for ischemia did not reveal an overall prognostic benefit from routine invasion.
  • Procedural MI increased early and spontaneous MI decreased later.
  • Angina-related quality-of-life benefit was concentrated in symptomatic patients.

Limitations

  • Left-main disease, severe symptoms despite therapy, severe LV dysfunction, and advanced CKD were excluded or handled separately.
  • Composite interpretation depends on MI definitions and changing hazards.
  • Strategy comparison included crossovers by design.

Why it matters

ISCHEMIA is the principal modern trial supporting initial medical management for many stable patients and sharpened revascularization toward symptoms and selected anatomy.

Cited by wiki pages

  • Stable CAD management
  • Revascularization
  • Overview