Medication Instead of Surgery or Procedures for Stable Myocardial Ischemia?

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What You Need to Know:

There has been a long-standing debate among experts in the cardiology community regarding the best management strategy for stable myocardial ischemia, and findings from a large clinical trial may help end that argument. The much anticipated International Study of Comparative Health Effectiveness With Medical and Invasive Approaches (ISCHEMIA) trial results were presented at the American Heart Association’s (AHA) annual meeting in Philadelphia as a late-breaking session Saturday afternoon. Outcomes may warrant significant changes for clinical practice.

Clinical trial subjects included those who experienced moderate to severe ischemia of the heart during a noninvasive stress test. Some of these patients experienced unstable angina, or chest pain while at rest. Patients with stable angina experienced chest pain on exertion, which resolved with rest. Current routine care for patients with stable ischemia follows an invasive approach which combines interventional therapy with medications and lifestyle changes for long-term management. ISCHEMIA study findings in the routine care group with stable symptoms showed that the addition of invasive procedures and/ or surgery, including cardiac catheterization with coronary stenting or coronary artery bypass grafting (CABG), along with medications and lifestyle changes did not decrease the overall rate of myocardial infarction or death compared with the non-routine care group who were given medications and lifestyle changes alone. These are landmark results that will likely alter the current long-standing standard of care for this population.    

The study also included patients with unstable ischemia, and it is important to highlight the different management recommendations for that group. For those with unstable ischemia, invasive coronary procedures were part of the management strategy which proved more effective in reducing symptoms than medications and lifestyle changes alone. Symptom improvement was most notable in patients who had more significant chest pain prior to coronary stenting and CABG. In patients experiencing acute myocardial infarction, emergency coronary stenting continues to be effective in reducing mortality. Detailed results of the ISCHEMIA study will be published in peer reviewed medical journals in 2020. 

Read More About Myocardial Ischemia and Coronary Artery Disease:

The Atlas and Synopsis of Family Medicine, 3e: Chapter 48. Coronary Artery Disease.

Hurst’s the Heart, 14e: Chapter 34. Coronary Blood Flow and Myocardial Ischemia

Critical Care: Chapter 24. Acute Cardiac Ischemia

Melanie Allison, DNP, MSN, RN, ACNP-BC

Executive Manager, Education & Learning, McGraw-Hill

Melanie Allison is the Executive Manager of Education & Learning with McGraw Hill. She earned her Doctor of Nursing Practice (DNP) degree and Post-Master’s Certificate in Nursing Education from The Johns Hopkins University. She earned her Master of Science in Nursing (MSN) degree, specializing as an acute care nurse practitioner (ACNP), from Vanderbilt University. Melanie has more than 20 years of experience as a registered nurse and nurse practitioner in adult cardiology and advanced lipid management. She is a part-time faculty member at a top school of nursing where she has taught for more than 16 years.