ESC Rene Laennec Lecture on Clinical Cardiology The role of revascularisation – from stable occlusion after myocardial infarction to stable ischaemic heart disease

Prof. Hochman is consistently humbled by the findings of her research. “As clinicians, we often think we know the answer. However, our research has often produced some very surprising results, sometimes the opposite of what we had expected. And this highlights to me that we should keep challenging assumptions so that we find the best treatment for patients.” 

Prof. Hochman’s Rene Laennec Lecture features three international trials she considers to be career highlights, starting with the SHOCK trial in cardiogenic shock.¹ “This is the trial that was probably the most practice changing to date,” said Prof. Hochman. “At the time it was conducted, the mortality rate for these patients was extremely high. Our trial showed that, compared with initial stabilisation with medical therapy followed by selection for cardiac catheterisation and revascularisation, emergency revascularisation improved survival, with 13 lives saved per 100 patients treated.” In the mid-2000s, she led the Occluded Artery Trial, which showed that routine percutaneous coronary intervention and stent insertion offered no benefit over medical therapy alone in stable high-risk patients with persistent occlusion of the infarction-related artery days after myocardial infarction.²

The results of the latest trial – the ISCHEMIA trial – published just this year, have generated much discussion.³ While the study demonstrated that an initial invasive strategy of cardiac catheterisation and revascularisation in patients with stable coronary artery disease and moderate-to-severe ischaemia had no overall outcomes’ advantage compared with medical therapy alone, the results also showed that patients with angina nevertheless derived a quality of life benefit. “This means that we can now give these patients information upon which to base an informed choice about whether or not to have revascularisation,” said Prof. Hochman, who is very passionate about engaging patients in the management of their disease. “Something we found from the ISCHEMIA trial was that less than half of patients entering the study had achieved satisfactory reduction of risk factors. We need to find ways to encourage the population to live healthy lifestyles and take medications proven to improve outcomes.” Other challenges Prof. Hochman sees in this area include the need to increase the rate at which randomised trial data are generated, to find ways to further improve outcomes for patients with cardiogenic shock – an area of research that has seen few developments since the SHOCK trial – and to do more to prevent sudden cardiac death.

Prof. Hochman continues to be fascinated by her research and is grateful to her mentors, particularly early mentorship by the late Doctor Bernadine Healy. “It is extremely rewarding to have been able to do challenging clinical trials, with collaborators around the world, that have expanded the base of medical knowledge and changed clinical practice for the better,” she concluded.