ISCHEMIA trial: a win for the optimal medical therapy in the management of stable coronary artery disease?

To the Editor, We have read with great interest the results of the ISCHEMIA trial1 of 5179 patients with moderate or severe ischemia who were randomized to receive an early invasive strategy of angiography plus revascularization, when necessary, or a conservative strategy of early optimal medical therapy and angiography if the medical therapy failed. As already known, the conclusion is that an early invasive strategy does not reduce the risk of cardiovascular ischemic events or all-cause mortality at the follow-up. However, it had beneficial effects because it reduced the occurrence of spontaneous myocardial infarction at the expense of a number of peri-PCI myocardial infarctions. Currently, this observation is under discussion probably because a different result was expected by researchers. In an interesting article2 it has been argued that the ISCHEMIA trial did not compare the benefits of coronary revascularization vs medical therapy, but assessed an early strategy of medical therapy vs early invasive treatment with angiography. In this sense, 79.4% of the patients from the invasive group were percutaneous or surgically revascularized vs 21.0% of the patients from the conservative group. A careful review of the supplementary data of the original publication1 reveals interesting additional data that we wish to share. A..