New Review Explores When to Use Invasive vs. Conservative Management in Coronary Artery Disease

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PASADENA, Calif. — June 12, 2023 — A new review co-authored by Dr. Robert A. Kloner, Chief Science Officer and Scientific Director of the Cardiovascular Research Institute at Huntington Medical Research Institutes (HMRI), and Dr. Shereif H. Rezkalla of Marshfield Clinic Health System, provides an updated synthesis of evidence guiding the use of invasive versus conservative treatment strategies in coronary artery disease (CAD).

Published in Clinical Medicine & Research (Volume 21, Number 2), the paper — “Invasive Versus Conservative Management in Coronary Artery Disease” — evaluates decades of clinical trials and contemporary practice, emphasizing the importance of patient selection, timing, and shared decision-making in optimizing outcomes.

The authors conducted a comprehensive literature review from 1985 to 2021, with particular focus on findings from the ISCHEMIA trial and related studies.

Key conclusions

  • ST-elevation myocardial infarction (STEMI): Immediate angiography and stenting remain the gold standard when performed promptly by experienced teams.

  • Non–ST-elevation myocardial infarction (NSTEMI): Early invasive strategies yield lower rates of death and reinfarction, particularly in high-risk patients.

  • Stable coronary artery disease: Optimal medical therapy (OMT) — including risk factor control, lifestyle modification, and pharmacologic therapy — should be the first-line approach. Invasive therapy should be reserved for cases of left main disease, left ventricular dysfunction, heart failure, or failed medical management.

  • Elderly and comorbid patients: Age alone should not preclude revascularization; decisions should weigh procedural risk against potential quality-of-life gains.

  • Advanced imaging: Coronary computed tomography angiography (CCTA) shows strong concordance with invasive angiography and is emerging as a non-invasive gatekeeper for diagnosis and management.

The review also notes that while early invasive treatment may improve angina relief and quality of life, long-term mortality outcomes between invasive and conservative strategies are comparable for most stable patients.

“Optimal therapy depends on the patient’s clinical profile,” said Dr. Kloner. “For stable disease, medical management and lifestyle optimization remain the foundation, while invasive approaches are critical for high-risk cases or when symptoms persist.”

The authors conclude that a shared decision-making model — combining clinical judgment, imaging evidence, and patient preferences — represents best practice for managing coronary artery disease in the modern era.

Full article: Clinical Medicine & Research, 2023