- Question
- Does an initial invasive strategy (coronary angiography and revascularization) added to medical therapy reduce cardiovascular events in patients with stable coronary disease, advanced kidney disease and moderate or severe ischemia, compared with an initial conservative strategy?
- Design
- Randomized, open-label (unmasked), international phase 4 trial enrolling 777 patients; median follow-up was 2.2 years.
- Population
- Patients with stable coronary disease, advanced chronic kidney disease (including patients on dialysis) and moderate or severe ischemia on stress testing.
- Intervention
- Initial invasive strategy: coronary angiography followed by revascularization (percutaneous coronary intervention or bypass surgery, if appropriate) added to optimal medical therapy.
- Control
- Initial conservative strategy: optimal medical therapy alone, with angiography and revascularization reserved for patients in whom medical therapy failed.
- Primary outcome
- Composite of death from any cause or nonfatal myocardial infarction.
- Results
- The primary outcome occurred in 123 patients in the invasive group and 129 in the conservative group (estimated 3-year event rate 36.4% vs. 36.7%; adjusted HR 1.01; 95% CI 0.79 to 1.29; P = 0.95). The key secondary outcome (death, nonfatal myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest) was similar (38.5% vs. 39.7%; HR 1.01; 95% CI 0.79 to 1.29).
- Safety
- The invasive strategy was associated with a higher incidence of stroke (HR 3.76; 95% CI 1.52 to 9.32; P = 0.004) and a higher incidence of death or initiation of dialysis (HR 1.48; 95% CI 1.04 to 2.11; P = 0.03).
- Conclusion
- In patients with stable coronary disease, advanced kidney disease and moderate or severe ischemia, an initial invasive strategy did not reduce the risk of death or nonfatal myocardial infarction compared with an initial conservative strategy.
- Why it matters
- It provided evidence in a population that earlier revascularization trials had routinely excluded, and supports starting with medical therapy in these patients, with no demonstrated benefit of a routine invasive strategy.
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 14, 2026