ISCHEMIA Subgroup Benefit — EECC MCQ

Correct answer: E — Patients with the most severe ischaemia (≥15% LV ischaemia) had a trend toward benefit from invasive strategy for spontaneous MI reduction; also, patients with refractory symptoms despite optimal medical therapy derive symptomatic benefit from revascularisation (Class I recommendation)

The ISCHEMIA trial overall showed no difference between invasive and conservative strategies for the primary composite. However, important nuances: (1) spontaneous MI was REDUCED by the invasive strategy (offset by INCREASED periprocedural MI — hence no net difference in total MI); (2) patients with the most extensive ischaemia (≥15% of LV) showed a TREND toward benefit from invasive strategy (not statistically significant in the primary analysis but consistent with physiological expectations); (3) quality of life (angina symptoms) improved MORE with the invasive strategy — supporting PCI/CABG for symptom management (Class I). The 2024 ESC CCS Guidelines now position revascularisation as: (1) Class I for SYMPTOM IMPROVEMENT when medical therapy fails; (2) Class I for PROGNOSTIC BENEFIT only in: left main disease, proximal LAD, and extensive ischaemia with reduced LVEF — scenarios excluded from or underrepresented in ISCHEMIA.

Reference: ESC (2024): CCS Guidelines; ISCHEMIA Trial