Invasive or Conservative Management of Chronic Coronary Disease Patients with a History of MI or Coronary Revascularization: Insights from the ISCHEMIA Trials

<title>Abstract</title> <p>Background Patients with chronic coronary disease (CCD) and a previous myocardial infarction (MI) or coronary revascularization, it remains unknow whether an invasive strategy can improve prognosis when compared to medical therapy. Methods This study was a secondary analysis of the ISCHEMIA trials (ISCHEMIA and ISCHEMIA-CKD), in which 5,956 patients with CCD were randomly assigned to an initial invasive or conservative treatment strategy. The primary outcome was the 4-year composite of cardiovascular (CV) death or MI. Results Among the 5,956 participants, 1,794 (30.1%) had a history of MI or coronary revascularization. Compared with those without such a history, these patients had a greater burden of cardiovascular risk factors and comorbidities at baseline and experienced a higher 4-year incidence of CV death or MI (18.2% vs. 14.5%). In participants with previous MI or coronary revascularization, the invasive strategy was associated with a lower 4-year risk of CV death or MI than the conservative strategy (15.9% vs. 20.6%, a difference of -4.7%; 95% confidence interval [CI]: -8.8% to -0.6%), By contrast, no significant difference was observed among patients without previous MI or coronary revascularization (13.9% vs. 15.0%, a difference of -1.1%; 95% CI: -3.7% to 1.5%). After multivariable adjustment, an invasive strategy remained independently associated with a lower risk of CV death or MI in patients with previous MI or coronary revascularization (adjusted hazard ratio: 0.77; 95% CI: 0.62 to 0.97). Conclusions Among patients with CCD, those with a history of MI or coronary revascularization were at substantially higher cardiovascular risk than those without such a history. In this subgroup, an initial invasive strategy was associated with a lower incidence of CV death or MI than an initial conservative strategy. Clinical Trial Registration URL https//www.clinicaltrials.gov. Unique identifier NCT01471522 (registered 15/11/2011) and NCT01985360 (registered 15/11/2013).</p>