title: 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.
authors: New York University School of Medicine, 530 First Avenue, SKI-9U, New York, NY, 10016, USA, Lawrence.Phillips@nyumc.org.
authors: Lawrence M
authors: LM
authors: Phillips
authors: Rory
authors: R
authors: Hachamovitch
authors: Daniel S
authors: DS
authors: Berman
authors: Ami E
authors: AE
authors: Iskandrian
authors: James K
authors: JK
authors: Min
authors: Michael H
authors: MH
authors: Picard
authors: Raymond Y
authors: RY
authors: Kwong
authors: Matthias G
authors: MG
authors: Friedrich
authors: Marielle
authors: M
authors: Scherrer-Crosbie
authors: Sean W
authors: SW
authors: Hayes
authors: Tali
authors: T
authors: Sharir
authors: Gilbert
authors: G
authors: Gosselin
authors: Marco
authors: M
authors: Mazzanti
authors: Roxy
authors: R
authors: Senior
authors: Rob
authors: R
authors: Beanlands
authors: Paola
authors: P
authors: Smanio
authors: Abhi
authors: A
authors: Goyal
authors: Mouaz
authors: M
authors: Al-Mallah
authors: Harmony
authors: H
authors: Reynolds
authors: Gregg W
authors: GW
authors: Stone
authors: David J
authors: DJ
authors: Maron
authors: Leslee J
authors: LJ
authors: Shaw
mesh_terms: D053805:Fractional Flow Reserve, Myocardial; D006801:Humans; D017202:Myocardial Ischemia / Q000503:physiopathology / Q000601:surgery*; D055414:Myocardial Perfusion Imaging; D009204:Myocardial Revascularization; D017410:Practice Guidelines as Topic; D016032:Randomized Controlled Trials as Topic; D016896:Treatment Outcome
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