geoffrey modest medical blogs

  A recent secondary analysis of the ISCHEMIA trial found that conservative management of stable angina found that the average number of days alive and not in the hospital was higher than with invasive management ( see  cad stable ischemia trial jamacard2021  in dropbox, or doi:10.1001/jamacardio.2021.1651 )   Details: -- 5179 patients enrolled in the ISCHEMIA trial were assessed for the prespecified analysis of days alive out of hospital (DAOH), which includes both death and days out of the hospital collectively -- patients had stable coronary disease with moderate or severe ischemia, randomized to invasive vs conservative management (angiography/revascularization vs meds, with both groups receiving optimal medical therapy) -- see  http://gmodestmedblogs.blogspot.com/2020/05/ischemia-trial-stable-angina-conserv.html  for details of the study Results: -- DAOH at one mon th, comparing conservative vs invasive management: 30.8 vs 28.4 days, p<0.001 --...

A substudy of the ISCHEMIA trial assessed patients with stable coronary disease but advanced kidney disease, also finding no benefit from an invasive strategy over medical management    (see  cad stable CKD med management ISCHEMIA nejm2020  in dropbox or DOI: 10.1056/NEJMoa1915925 ). See  http://gmodestmedblogs.blogspot.com/2020/05/ischemia-trial-stable-angina-conserv.html  for details/critique of the larger  ISCHEMIA trial)   Details: -- the ISCHEMIA-CKD study began enrollment 2 years after the ISCHEMIA trial, though the two ran in parallel and were conducted at most of the same sites -- 777 patients with advanced kidney disease had moderate or severe ischemia on stress testing -- all patients had an eGFR <30 (47%) or were on dialysis (53%)      --  not on dialysis: median eGFR 23;  dialysis: median duration 2 years/84% hemodialysis, 15% peritoneal -- median age 63, 69% male, 64% white/8% Blacks/26% Asian, 61...

As a small detour/reprieve from Covid:   Finally, the  ISCHEMIA  Trial was published (see  cad stable med management ISCHEMIA Nejm2020  in dropbox, or   DOI: 10.1056/NEJMoa1915922 ). I have no idea why it took almost 6 months to publish this, given that almost all key papers presented at the American Heart Association are published simultaneously   with their presentation  in New England Journal. This delay also happened with the IMPROVE-IT trial with ezetimibe. does sound a bit fishy.. Details: -- 5179 patients with moderate or severe ischemia were randomized to initial invasive strategy (angiography and revascularization when feasible) and medical therapy, vs medical therapy alone and angiography if medical therapy failed. Intensive medical therapy was applied to both groups equally -- patients were recruited from 2012 to 2018 from 320 sites in 37 countries -- median age 64, 77% male, 66% white/4% black/29% A...