To Bernard Lown, MD:
Sir, you are no longer a maverick. We should have listened to you.
It took over 40 years, but today, at the American Heart Association (AHA) Scientific Sessions 2019, we learned that you were right to stop referring "most patients with stable coronary artery disease (CAD) for cardiac angiography."
The ISCHEMIA trial showed that an invasive approach to patients with moderate to severe ischemia did not significantly reduce a composite endpoint of myocardial infarction (MI), cardiovascular (CV) death, hospitalization for unstable angina or heart failure, and cardiac arrest compared with a conservative medical strategy—without initial angiography. The hard endpoints of MI, CV death, and all-cause death also did not differ between the treatment arms.
ISCHEMIA produced clear results. This study changes cardiology practice and provides society an important new way to understand atherosclerotic heart disease.
Recall that before ISCHEMIA numerous trials showed no reduction of MI or death with an invasive strategy on top of optimal medical therapy. This is important because it adds confidence to the null result.
ISCHEMIA enrolled patients with significant CAD. There will be arguments about the severity of their ischemic burden. Do not be swayed. In the real world, patients like those enrolled in ISCHEMIA go to the cath lab and often have revascularization.
