Comparison of ischaemia-guided versus angiography-guided revascularization in stable ischaemic heart disease.

Abstract

Background: In patients with stable ischaemic heart disease (SIHD), both COURAGE and ISCHAEMIA trials demonstrated comparable outcomes with between percutaneous coronary intervention (PCI) and medical therapy, even with evidence of inducible ischaemia. The clinical utility of ischaemia-guided revascularization has therefore been questioned. Methods: We prospectively collected data on consecutive patients undergoing PCI for SIHD (excluding staged procedures) at six Victorian public hospitals between 2013-2018 from the Melbourne Interventional Group registry. Clinical characteristics and outcomes were compared between those with and without functional testing (exercise or pharmacological stress test, radionuclide, echo, FFR) prior to PCI. Results: Among the 4,641 patients with SIHD undergoing PCI, 2,867 (65.5%) underwent ischaemia-guided revascularization. A greater proportion in this group were younger, male, with a lower cardiovascular risk factor profile, although rates of diabetes were similar. Adherence to guideline-directed medical therapy was excellent in both groups. Over a mean follow-up of 2±1 year, 397 patients died (8.5%). On multivariate Cox-proportional hazards modelling, after adjusting for significant clinical and angiographic characteristics, ischaemia guided revascularization was a strong independent predictor of improved long-term mortality (hazard ratio 0.63; 95% CI 0.49-0.79, p<0.001). Conclusion: In patients with SIHD undergoing PCI, ischaemia-guided revascularization was independently associated with improved long-term survival. Use of functional testing to guide the decision for revascularization may have facilitated appropriate selection of patients for PCI.