- Question
- In patients with stable coronary disease and moderate or severe ischemia, does an initial invasive strategy with revascularization plus medical therapy lead to better clinical outcomes than medical therapy alone?
- Design
- International, open-label (unmasked) randomized trial of 5179 patients assigned to an initial invasive or an initial conservative strategy, with a median follow-up of 3.2 years.
- Population
- Patients with stable coronary disease and documented moderate or severe ischemia.
- Intervention
- Initial invasive strategy: coronary angiography and revascularization when feasible, together with optimal medical therapy.
- Control
- Initial conservative strategy: optimal medical therapy alone, with angiography reserved for medical therapy failure (acute coronary syndrome, ischemic heart failure, resuscitated cardiac arrest or refractory symptoms).
- Primary outcome
- Composite of death from cardiovascular causes, myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. A key secondary outcome was cardiovascular death or myocardial infarction.
- Results
- There were 318 primary outcome events in the invasive group and 352 in the conservative group. At 6 months the cumulative event rate was 5.3% vs. 3.4% (difference, 1.9 percentage points; 95% CI, 0.8 to 3.0), and at 5 years it was 16.4% vs. 18.2% (difference, -1.8 percentage points; 95% CI, -4.7 to 1.0). There were 145 deaths in the invasive group and 144 in the conservative group (HR, 1.05; 95% CI, 0.83 to 1.32).
- Safety
- The incidence of the primary outcome was sensitive to the definition of myocardial infarction used; a secondary analysis yielded more procedural myocardial infarctions of uncertain clinical importance.
- Conclusion
- The trial found no evidence that an initial invasive strategy reduced ischemic cardiovascular events or all-cause death compared with an initial conservative strategy over a median of 3.2 years.
- Why it matters
- It showed that in stable patients with moderate or severe ischemia, routine revascularization does not improve prognosis over optimal medical therapy, allowing invasive treatment to be reserved for those with refractory symptoms or other specific indications.
Card generated automatically with AI from the abstract of the original publication and the trial registry; every figure was checked against those sources. It may contain errors: verify the data at the source before using it for clinical decisions.
Generated on October 7, 2026