Vidal-Perez Rafael, Bouzas-Mosquera Alberto, Peteiro Jesus, Vazquez-Rodriguez Jose Manuel
Servicio de Cardiología, Unidad de Imagen y Función Cardíaca, Complexo Hospitalario Universitario A Coruña (CHUAC) Centro de Investigación Biomédica en Red (CIBERCV)-Instituto de Salud Carlos III, A Coruña 15006, Spain.
Servicio de Cardiología, Complexo Hospitalario Universitario A Coruña, A Coruña 15006, Spain.
World J Cardiol. 2021 Aug 26;13(8):237-242. doi: 10.4330/wjc.v13.i8.237.
During the last years two questions have been continuously asked in chronic coronary syndromes: (1) Do revascularization procedures (coronary artery bypass grafting or percutaneous coronary intervention) really improve symptoms of angina? and (2) Do these techniques improve outcomes, do they prevent new myocardial infarction events and cardiovascular death? Therefore, there was a need for a large definitive trial. This study was the ISCHEMIA trial, a large, multicentric trial sponsored by the National Heart, Lung, and Blood Institute. The main trial compared coronary revascularization and optimal medical treatment (OMT) OMT alone in 5179 patients enrolled after a stress test. During a median 3.2-year follow-up, 318 primary outcome events occurred; the adjusted hazard ratio for the invasive strategy as compared with the conservative strategy was 0.93 (95% confidence interval 0.80-1.08, 0.34). The ISCHEMIA trial deeply disrupted many of our prior attitudes regarding management strategies for patients with stable coronary artery disease. The findings underscore the benefits of disease-modifying OMT for stable coronary artery disease patients. The main purposes of ischemia assessment before this trial were: Diagnostic purposes, assessment of outcome, and adding to decision-making processes. Obviously, this changed after the trial results. The results of ISCHEMIA might challenge the current diagnostic approach for stable angina patients recommended in the last European Society of Cardiology guidelines on chronic coronary disease that were based on studies published before the ISCHEMIA trial. In this editorial we propose our approach based on the ISCHEMIA study and the pretest probability for a positive test in patients with chronic coronary syndromes.
在过去几年中，慢性冠状动脉综合征领域一直存在两个问题：（1）血运重建手术（冠状动脉旁路移植术或经皮冠状动脉介入治疗）是否真的能改善心绞痛症状？（2）这些技术能否改善预后，预防新的心肌梗死事件和心血管死亡？因此，需要进行一项大型确定性试验。这项研究就是缺血性心脏病优化药物治疗与血运重建策略比较研究（ISCHEMIA试验），这是一项由美国国立心肺血液研究所资助的大型多中心试验。主要试验比较了5179名在进行负荷试验后入组的患者接受冠状动脉血运重建与优化药物治疗（OMT）单独治疗的效果。在中位3.2年的随访期间，发生了318例主要结局事件；与保守策略相比，侵入性策略的调整后风险比为0.93（95%置信区间0.80 - 1.08，P = 0.34）。ISCHEMIA试验深刻改变了我们之前对稳定型冠状动脉疾病患者管理策略的许多看法。研究结果强调了针对稳定型冠状动脉疾病患者进行改善病情的优化药物治疗的益处。在该试验之前，缺血评估的主要目的是：诊断目的、预后评估以及辅助决策过程。显然，试验结果出来后情况发生了变化。ISCHEMIA试验的结果可能会挑战欧洲心脏病学会关于慢性冠状动脉疾病的最新指南中推荐的当前稳定型心绞痛患者诊断方法，该指南是基于ISCHEMIA试验之前发表的研究制定的。在这篇社论中，我们基于ISCHEMIA研究以及慢性冠状动脉综合征患者检测阳性的验前概率提出我们的方法。
