To Stent or Not to Stent?

Treating Angina After ISCHEMIA—The Impact of the ISCHEMIA Trial on the Indications for Angiography and Revascularization in Patients With Stable Coronary Artery Disease

Bernard J. Gersh; Deepak L. Bhatt


Eur Heart J. 2021;42(14) 

In This Article

Abstract and Introduction


  • The ISCHEMIA trial is a large, multinational trial sponsored by the National Heart, Lung, and Blood Institute, which has recently been published.[1] The main trial compares coronary revascularization and optimal medical therapy (OMT) vs. OMT alone in 5179 patients enrolled after stress testing, in addition to two ancillary studies in patients with chronic kidney disease (777 patients)[2] and a quality of life sub-study in the main ISCHEMIA trial, which enrolled 4617 patients.[3]

  • Crucial to placing the results of this important trial into perspective is a review of where we stood prior to the publication of ISCHEMIA, in regard to the indications for coronary revascularization vs. OMT in patients with chronic stable angina, more recently referred to as chronic coronary syndromes.[4]

Trials of the indications for revascularization have a long history dating back to the publication of the Veterans Affairs (VA) cooperative study of surgical vs. medical therapy for left main coronary disease.[5] Since that time, a considerable body of evidence has been acquired, albeit far from perfect, but notwithstanding, this has been the basis for most of our societal guidelines on the management of stable angina. Nonetheless, it is relevant to highlight the strengths and the limitations of what evidence we have and to clarify the gaps in our knowledge base that were the impetus and, in fact, the rationale for the ISCHEMIA trial.