Perspective

Journal of Nuclear Cardiology

, Volume 20, Issue 6, pp 969-975

First online:

Lessons learned from MPI and physiologic testing in randomized trials of stable ischemic heart disease: COURAGE, BARI 2D, FAME, and ISCHEMIA

  • Lawrence M. PhillipsAffiliated withNew York University School of Medicine Email author 
  • , Rory HachamovitchAffiliated withCleveland Clinic Foundation
  • , Daniel S. BermanAffiliated withCedars-Sinai Medical Center
  • , Ami E. IskandrianAffiliated withUniversity of Alabama – Birmingham
  • , James K. MinAffiliated withWeill Cornell Medical College
  • , Michael H. PicardAffiliated withMassachusetts General Hospital
  • , Raymond Y. KwongAffiliated withBrigham and Women’s Hospital
  • , Matthias G. FriedrichAffiliated withMontreal Heart Institute
  • , Marielle Scherrer-CrosbieAffiliated withMassachusetts General Hospital
    • , Sean W. HayesAffiliated withCedars-Sinai Medical Center
    • , Tali SharirAffiliated withAssuta Medical Center
    • , Gilbert GosselinAffiliated withMontreal Heart Institute
    • , Marco MazzantiAffiliated withUniversity Hospital of Ancona
    • , Roxy SeniorAffiliated withNorthwick Park Hospital
    • , Rob BeanlandsAffiliated withOttawa Heart Institute
    • , Paola SmanioAffiliated withInstituto Dante Pazzanese de Cardiologia
    • , Abhi GoyalAffiliated withEmory University School of Medicine
    • , Mouaz Al-MallahAffiliated withKing Abdulaziz Cardiac Center
    • , Harmony ReynoldsAffiliated withNew York University School of Medicine
    • , Gregg W. StoneAffiliated withNew York Presbyterian Hospital/Columbia University Medical Center
    • , David J. MaronAffiliated withVanderbilt University
    • , Leslee J. ShawAffiliated withEmory University School of Medicine

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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.

Keywords

Myocardial perfusion imaging ischemia coronary artery disease clinical trials