Complete revascularization provides better angina relief in chronic coronary disease patients: Analysis of Ischemia trial

"The benefit of complete revascularization was achieved in roughly 50% of patients who underwent PCI, and was most pronounced in patients with daily or weekly angina at baseline," the researchers reported. The study was published on July 17, 2023, in the Journal of the American College of Cardiology.

The study was focused on patients in the invasive arm of the ISCHEMIA trial, a landmark trial that revealed the strategy of adding revascularization with CABG or PCI on top of medical therapy failed to reduce the risk of major adverse cardiovascular events (MACE) in chronic coronary syndromes and moderate-to-severe ischemia at baseline. Patients randomly assigned to the invasive strategy did have a greater improvement in angina-related health status compared to those assigned to the conservative strategy, with the benefit seen in those with angina at baseline.

In the new analysis, Kreton Mavromatis, Emory University, Atlanta VA Healthcare System, Atlanta, Georgia, USA, and colleagues compared angina-related health outcomes of patients who received complete revascularization with PCI versus those who were incompletely revascularized and those treated conservatively with GDMT alone.

The researchers compared the following in the patients with CCD randomized to invasive (INV) versus conservative (CON) management in the ISCHEMIA trial: 1) the impact of anatomic and functional CR on health status compared with incomplete revascularization (ICR); and 2) the predicted impact of achieving CR in all INV patients compared with CON.

The 12-month health status was compared using multivariable regression adjusting for patient characteristics after independent core laboratory-defined CR vs ICR in INV patients who underwent revascularization. Then, propensity-weighted modelling was performed to estimate the treatment effect had CR or ICR been achieved in all INV patients, compared with CON.

The analysis revealed the following findings:

• Anatomic and functional complete revascularization was achieved in 43.3% and 57.8% of 1,641 INV patients, respectively.
• Among revascularized patients, CR was associated with improved Seattle Angina Questionnaire Angina Frequency compared with incomplete revascularization after adjustment for baseline differences.
• After modelling CR and ICR in all invasive patients, patients with CR and ICR each had greater improvements in health status than CON, with better health status with CR than ICR.
• The projected benefits of CR were most pronounced in patients with baseline daily/weekly angina and not seen in those with no angina.

"Health status improved more with CR compared with ICR or CON among patients with CCD in ISCHEMIA, particularly in those with frequent angina," the researchers wrote. "Functional and anatomic CR provided comparable improvements in quality of life."

Reference:

Mavromatis K, Jones PG, Ali ZA, et al. Complete revascularization and angina-related health status in the ISCHEMIA trial. J Am Coll Cardiol. 2023;82:295-313.