Physicians' Academy for Cardiovascular Education

Invasive vs conservative strategy did not result in benefit in patients with advanced CKD and SIHD

News - Nov. 17, 2019

International Study of Comparative Health Effectiveness With Medical and Invasive Approaches- Chronic Kidney Disease (ISCHEMIA-CKD): Primary Results of Clinical Outcomes

Presented during the AHA Scientific Sessions 2019 by Sripal Bangalore (New York Univ Sch of Med, New York, NY; ISCHEMIA-CKD Research Group.

Quality of Life data were presented by John A. Spertus (Mid America Heart Inst, Kansas City, MO; ISCHEMIA Research Group)

Introduction and methods

This CKD substudy of the ISCHEMIA trial aimed to answer the question whether in stable patients with advanced CKD and at least moderate ischemia on a stress test, is there a benefit of adding cardiac catheterization and, if feasible, revascularization to optimal medical therapy (OMT). In contemporary revascularization vs. medicine stable ischemic heart disease (SIHD), CKD patients are underrepresented or excluded.

Stable patients with moderate or severe ischemia and eGFR <30 mL/min/1.73m² or on dialysis were randomized to an invasive strategy (INV) or a conservative strategy (CON). INV consisted of optimal medical therapy (OMT) plus catheterization plus optimal revascularization (if suitable) and CON of OMT only, with catheterization reserved for OMT failure. The primary endpoint was a composite of death and myocardial infarction (MI). The trial had >80% power to detect 22-24% relative reduction in the primary endpoint, assuming an aggregate 4-year cumulative rate of approximately 41% to 48%.

777 Patients were randomized. Median follow-up for survivors in the INV group was 2.3 (1.9 to 3.2) year, and 99.2% of patients completed follow-up. In the CON group, median duration was 2.5 (1.9 – 3.2) years, and 99.7% completed it. On a stress test, baseline inducible ischemia was severe in 36%, and moderate in 64% of those in the INV group and 39%, and 61%, respectively in the CON group. The treatment groups showed no differences in risk factor management.

Quality of life was assessed at randomization, and throughout the follow-up period of up to 36 months. SAQ Angina Frequency Scale scores were used. A higher score reflects less angina.

Main results

Clinical outcomes

Quality of Life (QoL) outcomes


These data show that an initial invasive strategy did not result in a reduced risk of clinical outcomes as compared with an initial conservative strategy in patients with advanced CKD and SIHD. It should be noted that there were also low rates of revascularization in the INV arm, possibly because the sensitivity and specificity of stress testing in CKD patients are poor, and because there was no requirement for CCTA in the trial. The rate of procedural complications (stroke, acute kidney injury) was low, because sites were specifically trained to minimize risk of AKI after cardiac catheterization and revascularization. Thus, these findings may not be generalizable to centers with higher complication rates.

Regarding the QoL outcomes, no substantial improvement in angina control and QoL was seen. Given the large proportion of asymptomatic patients at baseline, we cannot exclude the possibility of a small benefit in symptomatic patients. Indeed, enrolment was very skewed towards less symptomatic patients; we may not have been able to discern a QoL benefit in more symptomatic patients.

- Our reporting is based on the information provided during AHA Scientific Sessions 2019 -

Read our summary of the results of the main ISCHEMIA trial Watch the video about the ISCHEMIA-CKD results

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