Case Background
A 57-year-old man presented to his cardiologist's office and reported a mild, pressure-like sensation in his chest during his daily workouts that resolves with rest. This symptom had been present for almost a year without significant change. He had a history of type 2 diabetes, hypertension, and hyperlipidemia. He had a non-ST-segment elevation myocardial infarction (MI) 3 years ago, for which he underwent percutaneous coronary intervention (PCI) of his right coronary artery. A 40% stenosis of his mid left anterior descending artery (LAD) was noted at that time. His current medications included carvedilol 12.5 mg twice daily, aspirin 81 mg once daily, atorvastatin 80 mg once daily, ramipril 2.5 mg once daily, and metformin 1,000 mg twice daily.
On examination, his temperature was 97.6 degrees F, heart rate was 78 bpm, blood pressure was 124/65, respiratory rate was 16, and oxygen saturation was 98% on room air. The remainder of his exam was unremarkable. An electrocardiogram showed normal sinus rhythm without any ischemic changes. Echocardiography showed a left ventricular ejection fraction of 50% and no regional wall motion abnormalities. An exercise nuclear stress test showed moderate ischemia in the LAD territory.
In light of available evidence, which of the following is true when counselling this patient?
Show Answer
The correct answer is: B. Non-urgent coronary angiography and revascularization of significant coronary artery disease will improve his quality of life if his angina symptoms are frequent or impact day-to-day activities.
Case Explanation
For this patient, whose symptoms are frequent and impact his day-to-day activities, repeat coronary angiography and revascularization of significant coronary artery disease will help improve quality of life by improving angina.
The randomized controlled trial ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) compared outcomes of early routine invasive strategy in addition to optimal medical therapy with a conservative strategy utilizing optimal medical therapy alone in patients with symptomatic stable ischemic heart disease (SIHD) and moderate to severe ischemia on noninvasive stress testing.1 The primary outcome was a composite of cardiovascular death, nonfatal MI, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. Over a mean follow-up period of 3.3 years, an initial invasive strategy compared with an initial conservative strategy did not demonstrate a reduced risk for the primary outcome, with an adjusted hazard ratio of 0.93 (95% confidence interval, 0.80-1.08; p = 0.34) (answers A and D). These findings are in line with prior randomized trials comparing outcomes of an invasive versus a conservative strategy in patients with SIHD.2 Similar findings were reported in ISCHEMIA-CKD (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches–Chronic Kidney Disease), which enrolled patients with advanced renal failure.
In the quality-of-life sub-analysis, among patients with angina at baseline, an initial invasive strategy led to durable improvement in angina control and quality of life compared with the conservative strategy (answers B and C).1,3-6 It is important to note that this trial excluded patients with greater than 50% left main coronary artery stenosis (assessed by coronary computed tomography), chronic kidney disease, left ventricular ejection fraction <35%, and New York Heart Association Class III-IV heart failure. The decision to pursue coronary angiography in patients with SIHD should ultimately be considered in the context of their background medical therapy, severity of anginal symptoms, and, most importantly, the patient's wishes following a rigorous physician-patient discussion.3,5,6
References
Maron DJ, Hochman JS, Reynolds HR, et al. Initial Invasive or Conservative Strategy for Stable Coronary Disease. N Engl J Med 2020;382:1395-407.
Boden WE, O'Rourke RA, Teo KK, et al. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med 2007;356:1503-16.
Nallamothu BK. The ISCHEMIA Trial Meets the Rashomon Effect: Lessons for Clinical Practice. Circ Cardiovasc Qual Outcomes 2020;13:e006527.
Dreyfuss B. It Happened So Fast ... I Guess, Yes, I Was Lucky. Circ Cardiovasc Qual Outcomes 2020;13:e006407.
Kirtane AJ. Practicing Art in Clinical Medicine: Clinical Commentary on "It Happened So Fast... I Guess, Yes, I Was Lucky". Circ Cardiovasc Qual Outcomes 2020;13:e006457.
Boden WE, Mancini GBJ. The Two-Edged Sword of Shared Clinical Decision-Making in the Post-ISCHEMIA World of Stable Coronary Artery Disease Management: Clinical Commentary on "It Happened So Fast ... I Guess, Yes, I Was Lucky". Circ Cardiovasc Qual Outcomes 2020;13:e006451.
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