Lessons learned from MPI and physiologic testing in randomized trials of stable ischemic heart disease: COURAGE, BARI 2D, FAME, and ISCHEMIA

Abstract

There is a preponderance of evidence that, in the setting of an acute coronary syndrome, an invasive approach using coronary revascularization has a morbidity and mortality benefit. However, recent stable ischemic heart disease (SIHD) randomized clinical trials testing whether the addition of coronary revascularization to guideline-directed medical therapy (GDMT) reduces death or major cardiovascular events have been negative. Based on the evidence from these trials, the primary role of GDMT as a front line medical management approach has been clearly defined in the recent SIHD clinical practice guideline; the role of prompt revascularization is less precisely defined. Based on data from observational studies, it has been hypothesized that there is a level of ischemia above which a revascularization strategy might result in benefit regarding cardiovascular events. However, eligibility for recent negative trials in SIHD has mandated at most minimal standards for ischemia. An ongoing randomized trial evaluating the effectiveness of randomization of patients to coronary angiography and revascularization as compared to no coronary angiography and GDMT in patients with moderate-severe ischemia will formally test this hypothesis. The current review will highlight the available evidence including a review of the published and ongoing SIHD trials.

Prognostic Determinants of Coronary Atherosclerosis in Stable Ischemic Heart Disease

“…[34][35][36] It is important to note that in both COURAGE and BARI 2D, minimal eligibility criteria were used based on stress testing findings. 37,38 Neither COURAGE nor BARI 2D provide reliable guidance as to whether the presence or degree of ischemia should be considered when determining the potential benefits of prompt revascularization.…”

Immortality time and serial myocardial perfusion imaging: Only those who do not die may repeat the exam

“…1,2 MPI is also commonly used as a gatekeeper to select patients for coronary revascularization. 3,4 The degree of left ventricular (LV) dysfunction and the extent and magnitude of inducible myocardial ischemia are important prognostic variables that can be assessed by MPI. Transient ischemic LV cavity dilation is another high-risk variable associated with the presence of severe angiographic CAD 5 and with an adverse outcome.…”

“…The ongoing International Study of Comparative Health Effectiveness With Medical and Invasive Approaches (ISCHEMIA) Trial attempts to demonstrate the extent to which an angiographic-driven strategy for higher risk stable ischemic heart disease patients with moderate-severe ischemia will or will not improve clinical outcomes. 4 This trial will be completed in *2019. In the meantime, the data of El-Hajj et al 20 further suggest that if a patient has had 2 consecutive MPI studies performed for Figure 1.…”

Serial cardiac SPECT studies: Technical issues and clinical implications

“…They found that ischemia worsening is an independent predictor of death or myocardial infarction, resulting in significantly improved risk reclassification when added to previously Trial attempts to demonstrate the extent to which an angiographic-driven strategy for higher risk stable ischemic heart disease patients with moderate-severe ischemia will or will not improve clinical outcomes. 9 This trial will be completed in three years. In the meantime, recent data of El-Hajj et al 10 …”