ISCHEMIA

Initial invasive strategy: cardiac catheterization with revascularization (PCI or CABG) as indicated, plus optimal medical therapy

Initial conservative strategy: optimal medical therapy alone, with catheterization reserved for medical therapy failure

At a median follow-up of 3.2 years, the primary endpoint occurred in 13.3% of invasive vs 15.5% of conservative patients (adjusted HR 0.93; 95% CI, 0.80-1.08; p=0.34).

There was no difference in cardiovascular death (HR 0.92) or all-cause death (HR 1.05) between strategies.

The invasive group had higher rates of periprocedural MI early on, but lower rates of spontaneous MI over time, yielding no net benefit.

Quality of life was significantly better in the invasive group, particularly among patients with frequent angina at baseline.

The conservative group had a 23% crossover rate to catheterization, most commonly for worsening angina.

Patients with left main disease were excluded after coronary CTA screening, limiting generalizability to that high-risk subgroup.

The 23% crossover rate from conservative to invasive may have diluted between-group differences.

Follow-up of 3.2 years may be insufficient to detect long-term survival differences, particularly in patients with extensive disease who may benefit from CABG.