The New Role of Cardiac Imaging Following the ISCHEMIA Trial.

PURPOSE OF REVIEW: This review is aimed at summarizing the recently published ISCHEMIA trial (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) and how its findings may impact cardiac imaging for stable ischemic heart disease (SIHD) moving forward.

RECENT FINDINGS: The ISCHEMIA trial compared an initial invasive management strategy with goal of complete coronary revascularization versus an initial medical therapy strategy among stable patients with newly diagnosed moderate to severe myocardial ischemia on non-invasive testing. The trial results showed that an early invasive strategy did not reduce the incidence of major cardiovascular events over 3.2 years of follow-up as compared to optimal medical therapy in patients with SIHD.

SUMMARY: The results of the landmark ISCHEMIA trial solidified the importance of guideline-directed medical therapy and have provided more evidence against the prevailing dogma that moderate to severe ischemia on traditional stress testing mandates coronary revascularization. This trial was not designed to compare different cardiac imaging and stress testing modalities for the assessment of coronary artery disease in patients undergoing their index evaluation for SIHD; however, its design, which included coronary computed tomographic angiography (CCTA) in most patients, and results have generated robust discussion regarding ways to improve non-invasive testing strategies in similar patient populations. We believe that increased utilization of CCTA to identify patients with and without high-risk SIHD, and advanced tests for ischemia, such as positron emission tomography and stress cardiac magnetic resonance imaging, when selected based on individual patient characteristics, may allow for improved decision-making and outcomes.