No Survival Benefit for Invasive Management of Stable CAD

An interim report of a US randomized trial in patients with stable coronary disease and moderate or severe ischemia concluded that there was no difference in all-cause mortality for an initial invasive strategy compared with an initial conservative strategy, with lower risk of cardiovascular mortality but higher risk of non-cardiovascular mortality for the initial invasive strategy over a median follow-up of 5.7 years. The trial included 5179 original participants, with median age 65 years, 23% women, 16% Hispanic, 4% Black, 42% diabetes, and median ejection fraction 0.60.  A total of 557 deaths accrued over a median follow-up of 5.7 years, including a total of 343 cardiovascular deaths, 192 non-cardiovascular deaths and 22 unclassified deaths. There was no significant difference in all-cause mortality between randomized treatment groups (7-year rate 12.7% in the invasive, 13.4% in the conservative strategy; adjusted hazard ratio (HR)=1.00). There was a lower 7-year rate cardiovascular mortality (6.4% vs. 8.6%, adjusted HR=0.78) with the initial invasive strategy but a higher 7-year rate of non-cardiovascular mortality (5.6% vs. 4.4%, adjusted HR=1.44) compared with the conservative strategy. Causes of non-cardiovascular death were predominantly malignancy, despite a similar prevalence of malignancy across groups at baseline. No heterogeneity of treatment effect was evident in prespecified subgroups, including multivessel coronary disease. The results are consistent with previous studies and provide important evidence for decision whether to add invasive management to guideline-directed medical therapy. Source: https://www.ahajournals.org/