ISCHEMIA Trial Key Finding — EECC MCQ

Correct answer: A — The ISCHEMIA trial showed that an initial invasive strategy (angiography + revascularisation) did NOT reduce death or MI compared with optimal medical therapy in stable CCS with moderate-severe ischaemia — medical therapy should be optimised before considering revascularisation for prognostic benefit

The ISCHEMIA trial (2020) randomised 5,179 patients with stable CCS and moderate-severe ischaemia on stress testing (≥10% LV ischaemia) to: initial invasive strategy (angiography → revascularisation if appropriate) vs conservative strategy (optimal medical therapy with angiography reserved for treatment failure). Results: NO difference in the primary composite of CV death, MI, or hospitalisation for unstable angina/HF/cardiac arrest over 3.3 years. The invasive group had a short-term increase in periprocedural MI but a long-term reduction in spontaneous MI, with no overall net benefit. The 2024 ESC CCS Guidelines incorporated this: revascularisation in stable CCS should target symptom improvement when medical therapy fails, rather than assuming prognostic benefit for all patients with ischaemia. Exceptions: left main disease (excluded from ISCHEMIA) and severely reduced LVEF.

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