ISCHEMIA Trial: Was It Worth the Wait?

Rasha Al-Lamee, MBBS, MA, PhD; Alice K. Jacobs, MD


Circulation. 2020;142(5):517-519. 

In This Article

What do the Ischemia Results Mean for our Clinical Practice?

ISCHEMIA should challenge our approach and make us consider changes to our clinical pathways, although we need to be cognizant of patients excluded from the trial (those with acute coronary syndrome within 2 months, high symptom burden, and severe left ventricular dysfunction). We should no longer believe that silent ischemia or high ischemic burden should necessitate early revascularization. With GDMT, there is no need to rush our decision making.

We need to reconsider how we use stress tests to diagnose ischemia. Using these tests in asymptomatic patients to determine the need for revascularization or for routine surveillance may no longer be valid. Perhaps we should move toward a primary role for computed tomographic angiography to exclude left main disease and to minimize the role of imaging tests while preserving functional tests for the diagnosis and assessment of hemodynamic response to exercise. The future role of invasive physiology in guiding treatment will also require thought. These will be important considerations as we integrate the findings of ISCHEMIA into our clinical practice.

Although the debate will no doubt continue, the lasting legacy of ISCHEMIA should be that, against all the odds, well-performed investigator-driven research answering important clinical questions is essential to the advancement of our knowledge. The results of ISCHEMIA should be used to educate and modify our clinical practice, even if they are unexpected and do not validate our preconceived beliefs. On the basis of the findings, what we have learned, and the implications for patient care, the ISCHEMIA trial was clearly worth the wait.