Impact of Complete Revascularization in the ISCHEMIA Trial

Gregg W. Stone; Ziad A. Ali; Sean M. O'Brien; Grace Rhodes; Philippe Genereux; Sripal Bangalore; Kreton Mavromatis; Jennifer Horst; Ovidiu Dressler; Kian Keong Poh; Ranjit K. Nath; Nagaraja Moorthy; Adam Witkowski; Sudhanshu K. Dwivedi; Olga Bockeria; Jiyan Chen; Paola E.P. Smanio; Michael H. Picard; Bernard R. Chaitman; Daniel S. Berman; Leslee J. Shaw; William E. Boden; Harvey D. White; Stephen E. Fremes; Yves Rosenberg; Harmony R. Reynolds; John A. Spertus; Judith S. Hochman; David J. Maron; ISCHEMIA Research Group; Joseph Selvanayagam

doi:10.1016/j.jacc.2023.06.015

Impact of Complete Revascularization in the ISCHEMIA Trial

Gregg W. Stone, Ziad A. Ali, Sean M. O'Brien, Grace Rhodes, Philippe Genereux, Sripal Bangalore, Kreton Mavromatis, Jennifer Horst, Ovidiu Dressler, Kian Keong Poh, Ranjit K. Nath, Nagaraja Moorthy, Adam Witkowski, Sudhanshu K. Dwivedi, Olga Bockeria, Jiyan Chen, Paola E.P. Smanio, Michael H. Picard, Bernard R. Chaitman, Daniel S. BermanLeslee J. Shaw, William E. Boden, Harvey D. White, Stephen E. Fremes, Yves Rosenberg, Harmony R. Reynolds, John A. Spertus, Judith S. Hochman, David J. Maron, ISCHEMIA Research Group, Joseph Selvanayagam

College of Medicine and Public Health

Research output: Contribution to journal › Article › peer-review

24 Citations (Scopus)

Abstract

Background: Anatomic complete revascularization (ACR) and functional complete revascularization (FCR) have been associated with reduced death and myocardial infarction (MI) in some prior studies. The impact of complete revascularization (CR) in patients undergoing an invasive (INV) compared with a conservative (CON) management strategy has not been reported.

Objectives: Among patients with chronic coronary disease without prior coronary artery bypass grafting randomized to INV vs CON management in the ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial, we examined the following: 1) the outcomes of ACR and FCR compared with incomplete revascularization; and 2) the potential impact of achieving CR in all INV patients compared with CON management.

Methods: ACR and FCR in the INV group were assessed at an independent core laboratory. Multivariable-adjusted outcomes of CR were examined in INV patients. Inverse probability weighted modeling was then performed to estimate the treatment effect had CR been achieved in all INV patients compared with CON management.

Results: ACR and FCR were achieved in 43.4% and 58.4% of 1,824 INV patients. ACR was associated with reduced 4-year rates of cardiovascular death or MI compared with incomplete revascularization. By inverse probability weighted modeling, ACR in all 2,296 INV patients compared with 2,498 CON patients was associated with a lower 4-year rate of cardiovascular death or MI (difference −3.5; 95% CI: −7.2% to 0.0%). In comparison, the event rate difference of cardiovascular death or MI for INV minus CON in the overall ISCHEMIA trial was −2.4%. Results were similar but less pronounced with FCR.

Conclusions: The outcomes of an INV strategy may be improved if CR (especially ACR) is achieved.

Original language	English
Pages (from-to)	1175-1188
Number of pages	14
Journal	Journal of The American College of Cardiology
Volume	82
Issue number	12
DOIs	https://doi.org/10.1016/j.jacc.2023.06.015
Publication status	Published - 19 Sept 2023

Keywords

complete revascularization
coronary artery disease
ischemia
prognosis
revascularization

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Stone, G. W., Ali, Z. A., O'Brien, S. M., Rhodes, G., Genereux, P., Bangalore, S., Mavromatis, K., Horst, J., Dressler, O., Poh, K. K., Nath, R. K., Moorthy, N., Witkowski, A., Dwivedi, S. K., Bockeria, O., Chen, J., Smanio, P. E. P., Picard, M. H., Chaitman, B. R., ... Selvanayagam, J. (2023). Impact of Complete Revascularization in the ISCHEMIA Trial. Journal of The American College of Cardiology, 82(12), 1175-1188. https://doi.org/10.1016/j.jacc.2023.06.015

@article{4f6d5c0e41564e04a59f491c887a98a4,

title = "Impact of Complete Revascularization in the ISCHEMIA Trial",

abstract = "Background: Anatomic complete revascularization (ACR) and functional complete revascularization (FCR) have been associated with reduced death and myocardial infarction (MI) in some prior studies. The impact of complete revascularization (CR) in patients undergoing an invasive (INV) compared with a conservative (CON) management strategy has not been reported. Objectives: Among patients with chronic coronary disease without prior coronary artery bypass grafting randomized to INV vs CON management in the ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial, we examined the following: 1) the outcomes of ACR and FCR compared with incomplete revascularization; and 2) the potential impact of achieving CR in all INV patients compared with CON management. Methods: ACR and FCR in the INV group were assessed at an independent core laboratory. Multivariable-adjusted outcomes of CR were examined in INV patients. Inverse probability weighted modeling was then performed to estimate the treatment effect had CR been achieved in all INV patients compared with CON management. Results: ACR and FCR were achieved in 43.4% and 58.4% of 1,824 INV patients. ACR was associated with reduced 4-year rates of cardiovascular death or MI compared with incomplete revascularization. By inverse probability weighted modeling, ACR in all 2,296 INV patients compared with 2,498 CON patients was associated with a lower 4-year rate of cardiovascular death or MI (difference −3.5; 95% CI: −7.2% to 0.0%). In comparison, the event rate difference of cardiovascular death or MI for INV minus CON in the overall ISCHEMIA trial was −2.4%. Results were similar but less pronounced with FCR. Conclusions: The outcomes of an INV strategy may be improved if CR (especially ACR) is achieved.",

keywords = "complete revascularization, coronary artery disease, ischemia, prognosis, revascularization",

author = "Stone, {Gregg W.} and Ali, {Ziad A.} and O'Brien, {Sean M.} and Grace Rhodes and Philippe Genereux and Sripal Bangalore and Kreton Mavromatis and Jennifer Horst and Ovidiu Dressler and Poh, {Kian Keong} and Nath, {Ranjit K.} and Nagaraja Moorthy and Adam Witkowski and Dwivedi, {Sudhanshu K.} and Olga Bockeria and Jiyan Chen and Smanio, {Paola E.P.} and Picard, {Michael H.} and Chaitman, {Bernard R.} and Berman, {Daniel S.} and Shaw, {Leslee J.} and Boden, {William E.} and White, {Harvey D.} and Fremes, {Stephen E.} and Yves Rosenberg and Reynolds, {Harmony R.} and Spertus, {John A.} and Hochman, {Judith S.} and Maron, {David J.} and {ISCHEMIA Research Group} and William Boden and Robert Harrington and David Williams and Alexander, {Karen P.} and Jeffrey Berger and Daniel Mark and Christie Ballantyne and Rafael Beyar and Balram Bhargava and Chris Buller and Carvalho, {Antonio (Tony)} and Rafael Diaz and Rolf Doerr and Vladimir Dzavik and Shaun Goodman and Gilbert Gosselin and Rory Hachamovitch and Christian Hamm and Claes Held and Malte Helm and Kurt Huber and Lixin Jiang and Matyas Keltai and Shun Kohsaka and Irene Lang and Renato Lopes and Jose Lopez-Sendon and Aldo Maggioni and John Mancini and {Bairey Merz}, {C. Noel} and James Min and Eric Peterson and Witold Ruzyllo and Joseph Selvanayagam and Roxy Senior and Tali Sharir and Gabriel Steg and Hanna Szwed and {Van de Werf}, Frans and William Weintraub and Harvey White and Karen Calfas and Champagne, {Mary Ann} and Michael Davidson and Jerome Fleg and McCullough, {Peter A.} and Jonathan Newman and Peter Stone and Philippe Menasche and Robert Guyton and Michael Mack and Fred Mohr and Anupama Rao and Joe Sabik and Oz Shapira and David Taggart and James Tatoulis and Jim Blankenship and Sorin Brener and Chris Buller and Antonio Colombo and {de Bruyne}, Bernard and Dean Kereiakes and Thierry Lefevre and Jeffrey Moses and Alexander, {Karen P.} and Ken Mahaffey and Salvador Cruz-Flores and Nicholas Danchin and Eli Feen and Garcia, {Mario J.} and Paul Hauptman and Laddu, {Abhay A.} and Eugene Passamani and Pina, {Ileana L.} and Maarten Simoons and Hicham Skali and Kristian Thygesen and David Waters and Patricia Endsley and Gerard Esposito and Jeffrey Kanters and John Pownall and Dimitrios Stournaras and Matthias Friedrich and Kwong, {Raymond Y.} and Dana Oliver and Frank Harrell and Jeffrey Blume and Kerry Lee and Iftikhar Kullo and Bruce McManus and Kristin Newby and David Cohen and Raffaele Bugiardini and Jelena Celutkiene and Jorge Escobedo and Angela Hoye and Radmila Lyubarova and Deirdre Mattina and Jesus Peteiro and Paola Smanio and Dan Berman and Jonathan Leipsic and Roy Mathew and Mandeep Sidhu and Lawrence Friedman and Jeffrey Anderson and Jessica Berg and David DeMets and Gibson, {C. Michael} and Gervasio Lamas and Nicole Deming and Jonathan Himmelfarb and Pamela Ouyang and Pamela Woodard and Samuel Nwosu and Ruth Kirby and Neal Jeffries and Denaro, {Jean E.} and Stephanie Mavromichalis and Kevin Chan and Gia Cobb and Aira Contreras and Diana Cukali and Stephanie Ferket and Andre Gabriel and Antonietta Hansen and Arline Roberts and Anna Naumova and Michelle Chang and Sharder Islam and Graceanne Wayser and Solomon Yakubov and Michelle Yee and Caroline Callison and Isabelle Hogan and Albertina Qelaj and Charlotte Pirro and {Van Loo}, Kerrie and Brianna Wisniewski and Margaret Gilsenan and Bevin Lang and Samaa Mohamed and Shari Esquenazi-Karonika and Patenne Mathews and Vincent Setang and Mark Xavier and Akshay Bagai and Samuel Broderick and Michelle Crowder and Derek Cyr and Jyotsna Garg and Xiangqiong Gu and Lisa Hatch and Anne Heath and Zhen Huang and Jeff Leimberger and Jill Marcus and Courtney Page and Wanda Parker and Wayne Pennachi and Frank Rockhold and Susanna Stevens and Allegra Stone and Omar Thompson and Sheri Ussery and Jennifer White and Williams, {Mary (Kaye)} and Weibing Xing and Songlin Zhu and Kevin Anstrom and Khaula Baloch and Janet Blount and Patricia Cowper and Linda Davidson-Ray and Laura Drew and Tina Harding and Knight, {J. David} and {Minshall Liu}, Diane and Betsy O'Neal and Thomas Redick and Philip Jones and Karen Nugent and {Jingyan Wang}, Grace and Lawrence Phillips and Abhinav Goyal and Holly Hetrick and Hayes, {Sean W.} and Friedman, {John D.} and Gerlach, {R. James} and Mark Hyun and Romalisa Miranda-Peats and Piotr Slomka and Louise Thomson and Kwong, {Raymond Y.} and Mongeon, {Francois Pierre} and Steven Michael and Judy Hung and Marielle Scherrer-Crosbie and Xin Zeng",

year = "2023",

month = sep,

day = "19",

doi = "10.1016/j.jacc.2023.06.015",

language = "English",

volume = "82",

pages = "1175--1188",

journal = "Journal of The American College of Cardiology",

issn = "0735-1097",

publisher = "Elsevier",

number = "12",

}

Stone, GW, Ali, ZA, O'Brien, SM, Rhodes, G, Genereux, P, Bangalore, S, Mavromatis, K, Horst, J, Dressler, O, Poh, KK, Nath, RK, Moorthy, N, Witkowski, A, Dwivedi, SK, Bockeria, O, Chen, J, Smanio, PEP, Picard, MH, Chaitman, BR, Berman, DS, Shaw, LJ, Boden, WE, White, HD, Fremes, SE, Rosenberg, Y, Reynolds, HR, Spertus, JA, Hochman, JS, Maron, DJ, ISCHEMIA Research Group & Selvanayagam, J 2023, 'Impact of Complete Revascularization in the ISCHEMIA Trial', Journal of The American College of Cardiology, vol. 82, no. 12, pp. 1175-1188. https://doi.org/10.1016/j.jacc.2023.06.015

TY - JOUR

T1 - Impact of Complete Revascularization in the ISCHEMIA Trial

AU - Stone, Gregg W.

AU - Ali, Ziad A.

AU - O'Brien, Sean M.

AU - Rhodes, Grace

AU - Genereux, Philippe

AU - Bangalore, Sripal

AU - Mavromatis, Kreton

AU - Horst, Jennifer

AU - Dressler, Ovidiu

AU - Poh, Kian Keong

AU - Nath, Ranjit K.

AU - Moorthy, Nagaraja

AU - Witkowski, Adam

AU - Dwivedi, Sudhanshu K.

AU - Bockeria, Olga

AU - Chen, Jiyan

AU - Smanio, Paola E.P.

AU - Picard, Michael H.

AU - Chaitman, Bernard R.

AU - Berman, Daniel S.

AU - Shaw, Leslee J.

AU - Boden, William E.

AU - White, Harvey D.

AU - Fremes, Stephen E.

AU - Rosenberg, Yves

AU - Reynolds, Harmony R.

AU - Spertus, John A.

AU - Hochman, Judith S.

AU - Maron, David J.

AU - ISCHEMIA Research Group

AU - Boden, William

AU - Harrington, Robert

AU - Williams, David

AU - Alexander, Karen P.

AU - Berger, Jeffrey

AU - Mark, Daniel

AU - Ballantyne, Christie

AU - Beyar, Rafael

AU - Bhargava, Balram

AU - Buller, Chris

AU - Carvalho, Antonio (Tony)

AU - Diaz, Rafael

AU - Doerr, Rolf

AU - Dzavik, Vladimir

AU - Goodman, Shaun

AU - Gosselin, Gilbert

AU - Hachamovitch, Rory

AU - Hamm, Christian

AU - Held, Claes

AU - Helm, Malte

AU - Huber, Kurt

AU - Jiang, Lixin

AU - Keltai, Matyas

AU - Kohsaka, Shun

AU - Lang, Irene

AU - Lopes, Renato

AU - Lopez-Sendon, Jose

AU - Maggioni, Aldo

AU - Mancini, John

AU - Bairey Merz, C. Noel

AU - Min, James

AU - Peterson, Eric

AU - Ruzyllo, Witold

AU - Selvanayagam, Joseph

AU - Senior, Roxy

AU - Sharir, Tali

AU - Steg, Gabriel

AU - Szwed, Hanna

AU - Van de Werf, Frans

AU - Weintraub, William

AU - White, Harvey

AU - Calfas, Karen

AU - Champagne, Mary Ann

AU - Davidson, Michael

AU - Fleg, Jerome

AU - McCullough, Peter A.

AU - Newman, Jonathan

AU - Stone, Peter

AU - Menasche, Philippe

AU - Guyton, Robert

AU - Mack, Michael

AU - Mohr, Fred

AU - Rao, Anupama

AU - Sabik, Joe

AU - Shapira, Oz

AU - Taggart, David

AU - Tatoulis, James

AU - Blankenship, Jim

AU - Brener, Sorin

AU - Buller, Chris

AU - Colombo, Antonio

AU - de Bruyne, Bernard

AU - Kereiakes, Dean

AU - Lefevre, Thierry

AU - Moses, Jeffrey

AU - Alexander, Karen P.

AU - Mahaffey, Ken

AU - Cruz-Flores, Salvador

AU - Danchin, Nicholas

AU - Feen, Eli

AU - Garcia, Mario J.

AU - Hauptman, Paul

AU - Laddu, Abhay A.

AU - Passamani, Eugene

AU - Pina, Ileana L.

AU - Simoons, Maarten

AU - Skali, Hicham

AU - Thygesen, Kristian

AU - Waters, David

AU - Endsley, Patricia

AU - Esposito, Gerard

AU - Kanters, Jeffrey

AU - Pownall, John

AU - Stournaras, Dimitrios

AU - Friedrich, Matthias

AU - Kwong, Raymond Y.

AU - Oliver, Dana

AU - Harrell, Frank

AU - Blume, Jeffrey

AU - Lee, Kerry

AU - Kullo, Iftikhar

AU - McManus, Bruce

AU - Newby, Kristin

AU - Cohen, David

AU - Bugiardini, Raffaele

AU - Celutkiene, Jelena

AU - Escobedo, Jorge

AU - Hoye, Angela

AU - Lyubarova, Radmila

AU - Mattina, Deirdre

AU - Peteiro, Jesus

AU - Smanio, Paola

AU - Berman, Dan

AU - Leipsic, Jonathan

AU - Mathew, Roy

AU - Sidhu, Mandeep

AU - Friedman, Lawrence

AU - Anderson, Jeffrey

AU - Berg, Jessica

AU - DeMets, David

AU - Gibson, C. Michael

AU - Lamas, Gervasio

AU - Deming, Nicole

AU - Himmelfarb, Jonathan

AU - Ouyang, Pamela

AU - Woodard, Pamela

AU - Nwosu, Samuel

AU - Kirby, Ruth

AU - Jeffries, Neal

AU - Denaro, Jean E.

AU - Mavromichalis, Stephanie

AU - Chan, Kevin

AU - Cobb, Gia

AU - Contreras, Aira

AU - Cukali, Diana

AU - Ferket, Stephanie

AU - Gabriel, Andre

AU - Hansen, Antonietta

AU - Roberts, Arline

AU - Naumova, Anna

AU - Chang, Michelle

AU - Islam, Sharder

AU - Wayser, Graceanne

AU - Yakubov, Solomon

AU - Yee, Michelle

AU - Callison, Caroline

AU - Hogan, Isabelle

AU - Qelaj, Albertina

AU - Pirro, Charlotte

AU - Van Loo, Kerrie

AU - Wisniewski, Brianna

AU - Gilsenan, Margaret

AU - Lang, Bevin

AU - Mohamed, Samaa

AU - Esquenazi-Karonika, Shari

AU - Mathews, Patenne

AU - Setang, Vincent

AU - Xavier, Mark

AU - Bagai, Akshay

AU - Broderick, Samuel

AU - Crowder, Michelle

AU - Cyr, Derek

AU - Garg, Jyotsna

AU - Gu, Xiangqiong

AU - Hatch, Lisa

AU - Heath, Anne

AU - Huang, Zhen

AU - Leimberger, Jeff

AU - Marcus, Jill

AU - Page, Courtney

AU - Parker, Wanda

AU - Pennachi, Wayne

AU - Rockhold, Frank

AU - Stevens, Susanna

AU - Stone, Allegra

AU - Thompson, Omar

AU - Ussery, Sheri

AU - White, Jennifer

AU - Williams, Mary (Kaye)

AU - Xing, Weibing

AU - Zhu, Songlin

AU - Anstrom, Kevin

AU - Baloch, Khaula

AU - Blount, Janet

AU - Cowper, Patricia

AU - Davidson-Ray, Linda

AU - Drew, Laura

AU - Harding, Tina

AU - Knight, J. David

AU - Minshall Liu, Diane

AU - O'Neal, Betsy

AU - Redick, Thomas

AU - Jones, Philip

AU - Nugent, Karen

AU - Jingyan Wang, Grace

AU - Phillips, Lawrence

AU - Goyal, Abhinav

AU - Hetrick, Holly

AU - Hayes, Sean W.

AU - Friedman, John D.

AU - Gerlach, R. James

AU - Hyun, Mark

AU - Miranda-Peats, Romalisa

AU - Slomka, Piotr

AU - Thomson, Louise

AU - Kwong, Raymond Y.

AU - Mongeon, Francois Pierre

AU - Michael, Steven

AU - Hung, Judy

AU - Scherrer-Crosbie, Marielle

AU - Zeng, Xin

PY - 2023/9/19

Y1 - 2023/9/19

N2 - Background: Anatomic complete revascularization (ACR) and functional complete revascularization (FCR) have been associated with reduced death and myocardial infarction (MI) in some prior studies. The impact of complete revascularization (CR) in patients undergoing an invasive (INV) compared with a conservative (CON) management strategy has not been reported. Objectives: Among patients with chronic coronary disease without prior coronary artery bypass grafting randomized to INV vs CON management in the ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial, we examined the following: 1) the outcomes of ACR and FCR compared with incomplete revascularization; and 2) the potential impact of achieving CR in all INV patients compared with CON management. Methods: ACR and FCR in the INV group were assessed at an independent core laboratory. Multivariable-adjusted outcomes of CR were examined in INV patients. Inverse probability weighted modeling was then performed to estimate the treatment effect had CR been achieved in all INV patients compared with CON management. Results: ACR and FCR were achieved in 43.4% and 58.4% of 1,824 INV patients. ACR was associated with reduced 4-year rates of cardiovascular death or MI compared with incomplete revascularization. By inverse probability weighted modeling, ACR in all 2,296 INV patients compared with 2,498 CON patients was associated with a lower 4-year rate of cardiovascular death or MI (difference −3.5; 95% CI: −7.2% to 0.0%). In comparison, the event rate difference of cardiovascular death or MI for INV minus CON in the overall ISCHEMIA trial was −2.4%. Results were similar but less pronounced with FCR. Conclusions: The outcomes of an INV strategy may be improved if CR (especially ACR) is achieved.

AB - Background: Anatomic complete revascularization (ACR) and functional complete revascularization (FCR) have been associated with reduced death and myocardial infarction (MI) in some prior studies. The impact of complete revascularization (CR) in patients undergoing an invasive (INV) compared with a conservative (CON) management strategy has not been reported. Objectives: Among patients with chronic coronary disease without prior coronary artery bypass grafting randomized to INV vs CON management in the ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial, we examined the following: 1) the outcomes of ACR and FCR compared with incomplete revascularization; and 2) the potential impact of achieving CR in all INV patients compared with CON management. Methods: ACR and FCR in the INV group were assessed at an independent core laboratory. Multivariable-adjusted outcomes of CR were examined in INV patients. Inverse probability weighted modeling was then performed to estimate the treatment effect had CR been achieved in all INV patients compared with CON management. Results: ACR and FCR were achieved in 43.4% and 58.4% of 1,824 INV patients. ACR was associated with reduced 4-year rates of cardiovascular death or MI compared with incomplete revascularization. By inverse probability weighted modeling, ACR in all 2,296 INV patients compared with 2,498 CON patients was associated with a lower 4-year rate of cardiovascular death or MI (difference −3.5; 95% CI: −7.2% to 0.0%). In comparison, the event rate difference of cardiovascular death or MI for INV minus CON in the overall ISCHEMIA trial was −2.4%. Results were similar but less pronounced with FCR. Conclusions: The outcomes of an INV strategy may be improved if CR (especially ACR) is achieved.

KW - complete revascularization

KW - coronary artery disease

KW - ischemia

KW - prognosis

KW - revascularization

UR - http://www.scopus.com/inward/record.url?scp=85169510571&partnerID=8YFLogxK

U2 - 10.1016/j.jacc.2023.06.015

DO - 10.1016/j.jacc.2023.06.015

M3 - Article

C2 - 37462593

AN - SCOPUS:85169510571

SN - 0735-1097

VL - 82

SP - 1175

EP - 1188

JO - Journal of The American College of Cardiology

JF - Journal of The American College of Cardiology

IS - 12

ER -

Impact of Complete Revascularization in the ISCHEMIA Trial

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