289 DIAGNOSTIC PATHWAY OF PATIENTS WITH CHRONIC CORONARY SYNDROME AFTER THE ISCHEMIA TRIAL PUBLICATION


 
 
 Patients with chronic coronary syndrome (CCS) can initially undergo an invasive (i.e., early referral to invasive coronary angiography [ICA]) or a conservative (i.e., anatomical or functional testing before ICA) management. The ISCHEMIA trial showed no difference between these two strategies in CCS patients with moderate-to-severe ischemia. The aim of our study was to assess whether the results of the ISCHEMIA trial impacted on the management of CCS patients.
 
 
 
 Trends in the management of patients with CCS in our centre, according to the ISCHEMIA trial publication date, were analyzed and patients categorized into pre-ISCHEMIA (before March 2020) and post-ISCHEMIA (from July 2020 to February 2022) groups, with an in-between blanking period of three months. The primary outcome was incidence of referral to ICA by coronary computed tomography angiography (CCTA). Secondary objectives included the incidence ischemia test-referred ICA, incidence of CCTA-referred ICA and subsequent percutaneous coronary intervention (PCI), incidence of ischemia test-referred ICA and subsequent PCI and incidence of CCTA-referred ICA without subsequent PCI. Differences between the pre-specified subpopulations (age ≥75 years, diabetes, chronic kidney disease [CKD], peripheral arterial disease [PAD], gender male, unstable angina, active smoking status, body mass index [BMI] >30, hypertension, family history of coronary artery disease [CAD], atrial fibrillation [AF], prior percutaneous coronary intervention [PCI], prior coronary artery bypass grafting [CABG]) and the general population of the study were tested using a regression analysis.
 
 
 
 A total of 2,365 patients were included, 487 (20.6%) and 1,878 (79.4%) in the pre-ISCHEMIA and post-ISCHEMIA groups, respectively. There were no notable between-group differences in baseline characteristics. The primary outcome occurred more frequently in the post-ISCHEMIA group (73.5% vs. 32.5%; p<0.01). Compared to pre-ISCHEMIA, the post-ISCHEMIA group displayed less referrals to ICA by ischemia testing (31.6% vs. 52.5%; p<0.01) and more ICA referrals by CCTA with subsequent PCI (8.3% vs. 12.0%; p<0.01). There were no within-group differences in ischemia test-referred ICA and PCI, and CCTA-referred ICA without subsequent PCI. A regression analysis between the primary endpoint incidence in the general population compared to the incidence in the pre-specified subpopulations showed no significant difference in the p values for interaction.
 
 
 
 In the first two years from publication, the ISCHEMIA trial significantly impacted on the decision-making algorithm for patients with CCS, increasing referral to ICA by CCTA and diminishing ICAs indicated by an ischemia test.
