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Diabetes, heart failure, and myocardial revascularization: Is there a new message from the ISCHEMIA trial?

Diabetes, Herzinsuffizienz und Myokardrevaskularisation: Gibt es Neuigkeiten von der ISCHEMIA-Studie?

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Abstract

There is no evidence that the indications for myocardial revascularization differ between patients with and without diabetes. Accepted indications include stable angina that cannot be adequately managed by medication, acute coronary syndromes, severely reduced left ventricular (LV) function due to coronary artery disease, left main stenosis, and advanced coronary artery disease causing substantial inducible ischemia. The recent ISCHEMIA trial challenged the criterion of ischemia. With respect to its primary endpoint, ISCHEMIA showed no benefit of an invasive strategy with systematic myocardial revascularization in patients with stable angina and moderate-to-severe ischemia compared with a conservative strategy. However, myocardial revascularization resulted in a statistically significant and clinically meaningful reduction in angina and an improvement in quality of life. There was a significant reduction in prognostically relevant spontaneous myocardial infarction (MI) in the long term, which came at the cost of an increased rate of peri-interventional MI that was of minor prognostic relevance. The risk profile and number of patients included in the ISCHEMIA trial, as well as the duration of follow-up, are not sufficient to show that the lower incidence of spontaneous infarcts improved survival. In ISCHEMIA, there was no heterogeneity in treatment effect depending on diabetes.

Zusammenfassung

Es gibt keine Hinweise, dass sich die Indikationen für eine Myokardrevaskularisation bei Patienten mit und ohne Diabetes unterscheiden. Zu den anerkannten Indikationen gehören eine stabile Angina, die medikamentös nicht angemessen behandelt werden kann, akute Koronarsyndrome, eine stark eingeschränkte linksventrikuläre Funktion aufgrund einer koronaren Herzkrankheit, eine Stenose des linken Hauptstamms und eine fortgeschrittene koronare Herzkrankheit, die eine erhebliche induzierbare Ischämie verursacht. In der 2020 publizierten ISCHEMIA-Studie wurde das Kriterium der Ischämie infrage gestellt. In Bezug auf ihren primären Endpunkt zeigte ISCHEMIA keinen Vorteil einer invasiven Strategie mit systematischer Myokardrevaskularisation bei Patienten mit stabiler Angina pectoris und mäßiger bis schwerer Ischämie im Vergleich zu einer konservativen Strategie. Die Myokardrevaskularisation führte jedoch zu einer statistisch signifikanten und klinisch bedeutsamen Verringerung der Angina pectoris und zu einer Verbesserung der Lebensqualität. Langfristig kam es zu einer signifikanten Verringerung prognostisch relevanter spontaner Myokardinfarkte (MI), allerdings auf Kosten einer erhöhten Rate periinterventioneller MI, die jedoch von geringerer prognostischer Relevanz waren. Das Risikoprofil und die Anzahl der in ISCHEMIA eingeschlossenen Patienten sowie die Dauer der Nachbeobachtung reichen nicht aus, um zu zeigen, dass die geringere Inzidenz spontaner Infarkte das Überleben verbesserte. In ISCHEMIA gab es keine Heterogenität des Behandlungseffekts in Abhängigkeit vom Diabetes.

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  1. Klinik für Kardiologie und Angiologie, Universitäts-Herzzentrum, Universitätsklinikum Freiburg, Campus Bad Krozingen, Südring 15, 79189, Bad Krozingen, Germany

    Franz-Josef Neumann

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Correspondence to Franz-Josef Neumann.

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F.-J. Neumann reports speaker fees from Amgen, Boston Scientific, and Daiichi Sankyo and consulting fees from Novartis as well as speaker fees to his institution from Bayer Healthcare, Biotronic, Boehringer Ingelheim, Edwards Lifesciences, Ferrer, and Pfizer; consulting fees to his institution from Boehringer Ingelheim; financial study support from Bayer Healthcare, Boston Scientific, Biotronic, Edwards Lifesciences, GlaxoSmithKline, Medtronic, and Pfizer.

For this article no studies with human participants or animals were performed by any of the authors. All studies mentioned were in accordance with the ethical standards indicated in each case.

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Neumann, FJ. Diabetes, heart failure, and myocardial revascularization: Is there a new message from the ISCHEMIA trial?. Herz 47, 442–448 (2022). https://doi.org/10.1007/s00059-022-05132-8

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