Long-Term Outcomes of Invasive vs Conservative Management in Stable Coronary Disease: Consistent Evidence From Extended Follow-Up Trials

Extended follow-up of three major trials consistently shows that an initial invasive strategy does not improve long-term survival or reduce myocardial infarction (MI) compared with initial conservative management in patients with stable coronary disease. In the COURAGE trial’s extended observational analysis of 959 US veterans (median follow-up 15 years, maximum 25 years), the 25-year cumulative incidence of death or MI was 91.0% with optimal medical therapy (OMT) alone versus 93.3% with upfront PCI plus OMT (HR, 1.01), with no difference in death (82.2% vs 83.9%; HR, 0.98) or MI (54.0% vs 54.6%; cause-specific HR, 1.01), although more than half of patients in each group eventually underwent revascularization and nearly half randomized to OMT alone never required it. In the ISCHEMIA long-term follow-up of 5179 patients (median 9 years), 11-year all-cause mortality was 25.8% with invasive management versus 26.9% with conservative management (adjusted HR, 0.97), with cardiovascular mortality of 15.8% versus 17.1% (adjusted HR, 0.88) and noncardiovascular mortality of 9.1% versus 8.1% (adjusted HR, 1.18); the Bayesian probability of a greater than 1 percentage-point survival benefit from the invasive strategy was only 18%. Similarly, in ISCHEMIA-CKD, among 777 patients with moderate or severe ischemia and advanced chronic kidney disease followed for a median of 8 years, all-cause mortality was 57.4% with invasive versus 56.8% with conservative management (adjusted HR, 1.05) and cardiovascular mortality was 40.3% versus 38.4% (adjusted HR, 1.06), with a restricted mean survival time difference of −99 days. Together, these findings do not support a routine strategy of elective upfront revascularization to reduce long-term death or MI in stable coronary disease, and they reinforce guideline-directed medical therapy as the foundation of initial management. Source: https://jamanetwork.com/; https://www.ahajournals.org/