Failed ISCHEMIA Trial or Failed Ischemia Testing?

The results of the ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approach) trial were presented at the American Heart Association Scientific Sessions in November, 2019 in Philadelphia, Pennsylvania, and recently published on March 30, 2020 in the New England Journal of Medicine. After an average follow-up of 3.5 years, invasive therapy did not reduce the major adverse cardiac event (MACE) rate compared with optimal medical therapy (OMT) in patients with stable ischemic heart disease. However, the ISCHEMIA trial results might stem from the revascularization of inappropriate vessels and from the lack of a lesion-specific ischemia detection algorithm to guide revascularization instead of conventional stress testing. The utilization of an initial computed tomography (CT) angiogram with or without fractional flow reserve CT could have produced better revascularization results.