International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) trial and the ap
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CRITICAL APPRAISAL OF TRIALS
International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) trial and the appropriateness of revascularization Pradeep Narayan 1 Received: 22 April 2020 / Revised: 30 April 2020 / Accepted: 8 May 2020 # Indian Association of Cardiovascular-Thoracic Surgeons 2020
Abstract The recently published ISCHEMIA trial which is a prospective randomized multi-centre trial has concluded that there was no evidence that an initial invasive strategy of revascularisation in patients with stable angina reduced the risk of ischaemic cardiovascular events or death from any cause. The trial has confirmed that patients with stable angina do not greatly benefit from revascularisation and optimal medical treatment (OMT) is an acceptable alternative. The trial has also confirmed that in patients with stable angina and end-stage renal impairment, OMT is once again an equally effective initial strategy. While the ISCHEMIA trial is one of the most rigorously and meticulously conducted trial, exclusion of symptomatic patients, recruitment of patients who are not known to derive significant benefit from revascularisation and those who were at low risk of clinical events, along with a short follow-up period, may all have contributed to the lack of difference seen between the groups. The fact that the ISCHEMIA trial does not represent the entire cohort of real-life patients requiring revascularisation should be borne in mind, and care should be taken in extrapolating these results to the wider group of patients requiring revascularisation for coronary artery disease. Keywords ISCHEMIA . CABG . Stable angina . Stable ischaemic heart disease . Stable coronary artery disease
The rationale of carrying out coronary artery bypass grafting (CABG) in patients with coronary artery disease (CAD) has been to improve survival, relieve angina and reduce the incidence of nonfatal outcomes. This rationale has been challenged by the findings of the International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) trial. It concluded that there was no study evidence that the initial invasive strategy of revascularisation reduced the risk of ischaemic cardiovascular events or death from any cause [1]. The findings have been the subject of interpretation and discussion among medical as well as non-medical community who have been quick to point out the irrationality of the medical profession in treating patients with CAD and even casted * Pradeep Narayan [email protected] 1
Department of Cardiac Surgery, NH Rabindranath Tagore International Institute of Cardiac Sciences, 124, EM Bypass, Mukundapur, Kolkata 700099, India
veiled aspersions of greed and unethical practices among doctors. It therefore becomes mandatory from a clinical point of view as well as a moral imperative to evaluate our practice in the light of the findings of the ISCHEMIA trial. The ISCHEMIA trial was a prospective randomized parallel multi-centre trial carried out across 37 cou
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