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The relevance of these studies today is speculative because contemporary secondary prevention-aspirin, beta-blockers, statins, ACE inhibitors, and lifestyle interventions-were used minimally if at all. These data suggest, but do not prove, that routine cardiac catheterization--which often le to ad hoc PCI through the diagnostic-therapeutic cascade--may not be required sua SIHD patients. However, most patients enrolled in COURAGE and BARI 2D who had ischemia severity documented at baseline had only mild or moderate ischemia, leaving open the question of the appropriate role of cardiac catheterization and revascularization among higher-risk patients with more severe ischemia. Observational data suggest that revascularization of patients with moderate-to-severe ischemia is associated with a lower mortality than medical therapy alone, but such data cannot establish a cause and effect relationship. In clinical practice only about half such patients are referred for cardiac catheterization, indicating equipoise.

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The relevance of these studies today is speculative because contemporary secondary prevention-aspirin, beta-blockers, statins, ACE inhibitors, and lifestyle interventions-were used minimally if at all.

These data suggest, but do not prove, that routine cardiac catheterization--which often le to ad hoc PCI through the diagnostic-therapeutic cascade--may not be required in SIHD patients. However, most patients enrolled in COURAGE and BARI 2D who had ischemia severity documented at baseline had only mild or moderate ischemia, leaving open the question of the appropriate role of cardiac catheterization and revascularization among higher-risk patients with more severe ischemia.

Observational data suggest that revascularization of escorg with moderate-to-severe ischemia is associated with a lower mortality than medical therapy alone, but such data cannot establish a cause and effect relationship. In clinical practice only about half such patients are referred for cardiac catheterization, indicating equipoise.

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This issue cannot be resolved using available data because all prior SIHD strategy trials enrolled patients after cardiac catheterization, introducing undefined selection biases e. Study protocol version 1. At a deated time during the trial, an analysis will be conducted to estimate the overall aggregate primary endpoint event rate and project the final of observed events. Escorf the estimated unconditional power i.

Change the primary endpoint to one that occurs more frequently. The current primary endpoint would become a secondary endpoint.

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The proposed new primary endpoint would be the composite of CV death, MI, resuscitated cardiac arrest, or hospitalization for unstable angina or heart failure. Follow the recommendation of an independent advisory panel.

Members of this panel will not have access to unblinded data by treatment group or other data that may bias their recommendation. Study protocol v2.

The protocol addendum describes the NHLBI-approved reduction in sample size and escoet of recruitment and follow-up due to slower than projected recruitment. The pre-specified first analysis for monitoring and projecting the final aggregate of primary endpoint events was conducted in Inthe projected need to increase the power by extending follow-up and elevating the 5-component secondary endpoint to become primary was discussed at Steering Committee and Investigator meetings and communicated by.

The panel also recommended extension of follow-up.

This was communicated to the Steering Committee and Investigators at August escorh November meetings and by. The last visit date was June 30, See Maron DJ et al.

Am Heart J. PMC for additional details about modifications to the trial while it was being conducted.

Analysis of Patients' Health Status as a Key Secondary Endpoint A key secondary objective of the ISCHEMIA trial is to compare the quality of life outcomes-patients' symptoms, functioning and well-being-between those ased to an invasive strategy as compared with a conservative strategy. In the protocol, angina frequency and disease-specific quality of life measured by the Seattle Angina Questionnaire SAQ Angina Frequency and Quality of Life scales, respectively, are described as the tools that will be used to make this comparative assessment.

Recent work has indicated that it is possible mancinl combine the information from the individual domain scores in the SAQ into a new Summary Score that captures the information from the SAQ Angina Frequency, Physical Limitation and Quality of Life scales into a single overall score. The advantages of using a summary score as the primary measure of QOL effects of a therapy are a single primary endpoint comparison rather than two or three eliminating concerns some may have about multiple mancinj and a more intuitive holistic patient-centric interpretation of the effectiveness .