Cardiology ·
ISCHEMIA-EXTEND Finds No Long-Term Mortality Difference Between Management Strategies
In extended follow-up of 5,179 participants in the randomized ISCHEMIA trial, an initial invasive strategy was compared with an initial conservative strategy for chronic coronary disease. At 11 years, all-cause mortality did not differ significantly between groups.
- 11-year all-cause mortality did not differ significantly between strategies.
- The trial excluded patients with left main disease or unacceptable angina.
- Findings apply to the population enrolled in ISCHEMIA.
ISCHEMIA randomized 5,179 patients with chronic coronary disease and moderate or severe ischemia at 320 sites in 37 countries to an initial invasive strategy—guideline-directed medical therapy plus angiography and revascularization when feasible—or an initial conservative strategy of medical therapy, with invasive management if medical treatment failed. Participants had left ventricular ejection fraction of at least 35%; those with left main disease, unacceptable angina, or a recent acute coronary syndrome were excluded. Median follow-up was 9 years, with follow-up extending to 13.4 years.
At 11 years, estimated all-cause mortality was 25.8% with the invasive strategy and 26.9% with the conservative strategy (adjusted hazard ratio, 0.97; 95% CI, 0.86-1.09). The estimated difference was −1.0 percentage point (95% CI, −4.2 to 2.1), and restricted mean survival differed by 14 days (95% CI, −41 to 70). Cardiovascular mortality was also not significantly different: 15.8% versus 17.1% (adjusted hazard ratio, 0.88; 95% CI, 0.75-1.02).
The findings do not show a significant long-term survival advantage for routine invasive management in this trial population. They do not address all patients with coronary disease, including those excluded from the trial, and mortality results alone do not establish equivalence in other outcomes such as symptoms.
In practice
For patients resembling those enrolled in ISCHEMIA—chronic coronary disease with moderate or severe ischemia, preserved or mildly reduced ejection fraction, and without left main disease, unacceptable angina, or recent acute coronary syndrome—this extended randomized follow-up found no significant difference in 11-year all-cause mortality between initial invasive and conservative strategies. The results do not demonstrate a survival benefit from routine invasive management in this population, but they do not establish that the strategies are equivalent for other outcomes or apply to excluded, higher-risk groups.
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JAMA: Long-Term Survival After Initial Invasive or Conservative Management of Stable Coronary Disease in ISCHEMIA-EXTEND ↗This is an automated AI-condensed summary that has not yet been reviewed by an editor. Always consult the full item at the original source.