In the past, stress-induced ischemia was generally accepted as an indication for early revascularization (percutaneous coronary intervention or coronary artery bypass graft surgery) in patients with stable angina.1 However, the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE)2 and Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D)3 trials, which emphasized the use of optimal medical therapy (OMT), failed to demonstrate an advantage for early revascularization. Substudies of these trials tried to identify patients with enough ischemia to benefit from revascularization. In the stress nuclear substudy from COURAGE,4 patients who underwent baseline and follow-up single photon emission tomography (SPECT) imaging at 6 to 18 months experienced an improvement in ischemia more often if they were randomized to OMT and percutaneous coronary intervention than OMT alone. In patients with stress-induced ischemia involving 10% of the left ventricle or more, the improvement in ischemia was associated with a better long-term prognosis. This hypothesis-generating finding suggested the need for further trials.
Gibbons RJ. Is the Search for Enough Moderate-Severe Ischemia Nearly Over? JAMA Cardiol. 2019;4(3):203–205. doi:10.1001/jamacardio.2019.0024
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