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Late-Breaking Science: Initial invasive or conservative treatment for patients with stable ischaemic heart disease and a history of heart failure?

The ISCHEMIA trial recently found no evidence that the risk of cardiovascular (CV) events or all-cause death was reduced with an initial invasive strategy (angiography and revascularisation when feasible and medical therapy) compared with an initial conservative strategy (medical therapy alone with angiography if medical therapy failed) in patients with stable coronary disease, moderate or severe ischaemia and left ventricular ejection fraction (LVEF) >35%.1

Coronary Artery Disease, Acute Coronary Syndromes, Acute Cardiac Care
Heart Failure

In a Late-Breaking Science presentation today, Professor Renato Lopes (Duke Clinical Research Institute, Durham, NC, USA) described a comparison of CV outcomes in ISCHEMIA participants with a history of heart failure (HF) or left ventricular dysfunction (LVD) (defined as prior HF or LVEF <45% at randomisation) vs. those without a history of HF/LVD over the median 3.2-year follow-up period.

Of the total 5,179 patients studied in ISCHEMIA, 398 patients (7.7%) had prior HF/LVD and these patients had more comorbidities, particularly prior myocardial infarction (MI), stroke and hypertension than patients with no prior HF/LVD. Furthermore, the primary endpoint of ISCHEMIA (CV death, nonfatal MI, or hospitalisation for unstable angina, HF or resuscitated cardiac arrest) occurred more frequently in patients with a history of HF/LVD (4­-year cumulative incidence rate: 22.7% vs. 13.8%).

The key result of Prof. Lopes’ presentation was that patients with a history of HF/LVD had lower risk of the primary endpoint with an invasive strategy (17.2%) compared with an initial conservative strategy (29.3%). Consistent with the overall trial conclusion, there was no difference between groups for the primary endpoint in patients without a history of HF/LVD (p-interaction=0.055). Similar results were seen for the primary outcome with HF/LVD groups and non-HF/LVD groups when LVEF was analysed as a continuous variable.

These note-worthy findings suggest patients with stable ischaemic heart disease and a history of HF/LVD may derive benefit from an initial invasive strategy – this information might help physicians in the decision-making process when treating these high-risk patients.


1. Maron DJ, et al. N Engl J Med 2020;382:1395–1407.

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.