What is the Real Message of the International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) Trial for Academic and Practising Cardiologists?

Defining the best management strategies for patients with stable ischaemic heart disease (SIHD) has been the subject of scientific study for nearly 50 years since the advent of coronary artery bypass grafting (CABG) surgery by Favaloro in 1967 and, a decade later, the development of percutaneous coronary intervention (PCI) by Gruentzig in 1977. Randomised controlled trials of CABG surgery versus medical therapy were initiated in the late 1970s and 1980s in patients with SIHD and showed that revascularisation reduced MI and mortality in subsets of patients with three-vessel and left main coronary artery disease (CAD). In the 1990s, randomised controlled trials of PCI versus medical therapy, initially with balloon angioplasty (Angioplasty Compared to Medicine [ACME] and Second Randomised Intervention Treatment of Angina [RITA-2]), were similarly undertaken in SIHD patients and showed significantly better angina relief and treadmill exercise performance with PCI, although no reduction in death or MI. Nevertheless, the widespread availability of PCI greatly expanded the number of patients who could be revascularised safely and pushed revascularisation therapy to become routine for SIHD patients in many locales.