Stable Coronary Artery Disease (CAD) Management: An Invasive or Conservative Approach to Patients with ISCHEMIA?- Dr. Shaun Goodman
Jordan Harry, MSc Candidate (Translational Medicine)
At the October 1st Medical Grand Rounds, the Department of Medicine had the privilege of virtually hosting Dr. Shaun Goodman, a staff cardiologist and associate head in the Division of Cardiology at St. Michael's Hospital in Toronto. Dr. Goodman’s presentation was about coronary artery disease management: an invasive or conservative approach for patients with ischemia.
Dr. Goodman’s presentation began with a case study about a patient with ischemic heart disease. The audience was polled about their approach to treatment; invasive or conservative. The poll resulted in a split between the options, which demonstrated the current treatment divide. Dr. Goodman used prior studies to describe the rationale for each strategy. He indicated that previous studies may not be accurate due to minimal randomization, and their predating of current cardiovascular drug therapies.
Dr. Goodman introduced the International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) trial which attempted to fill gaps left by previous studies. This trial aimed to determine if an initially invasive approach resulted in better clinical and angina related quality of life outcomes than an initially conservative approach. In addition to the main ISCHEMIA trial, patients with chronic kidney disease (CKD) amongst other conditions were included in a separate ISCHEMIA-CKD trial. Dr. Goodman explained the decision making processes behind the trial and the decisions to include/exclude participants.
There were no significant differences in the primary goal of the trial, which was the rate of death from cardiovascular related causes. In regards to quality of life, patients in the invasive interventional group reported a reduction in angina relative to the conservative group. The magnitude of this benefit was dependent on the quantity of angina present at baseline, the more angina, the better the reduction. In the ISCHEMIA-CKD trial there was no significant difference in the primary endpoint of death of any cause or myocardial infarction. Unlike the main ISCHEMIA trial there was no change in angina in the interventional group. The findings did not provide clarity about a superior approach, but did indicate that it is relatively safe to defer revascularization procedures in favour of less invasive approaches. Dr. Goodman noted that the ISCHEMIA trial may have ended prior to visible benefits for the invasive approach, and indicated that the follow up period has since been extended.
During the post-Grand Rounds discussion Dr. Goodman and Translational Medicine (TMED) students focused on how the ISCHEMIA trial could benefit patients. Many trials prior to ISCHEMIA were observational studies with conflicting results, Dr. Goodman explained how various functional tests were incorporated into the trial to improve the standard of evidence. The discussion transitioned to how the findings applied to patients with CKD or atherosclerosis. Dr. Goodman indicated that less invasive approaches should be used for patients with unstable plaques, so they are not dislodged by catheterization. Additionally, gender based differences in cardiovascular disease were covered, as there were less females enrolled in ISCHEMIA than males, he suggested that there may be multiple reasons for this and that these differences in ISCHEMIA may be further explored.
The discussion became about the extensive coverage of the ISCHEMIA trial in the media. The ISCHEMIA trial resulted in an increased favour of anatomical imaging. Two proposed modalities; positron emission tomography (PET), and coronary computed tomography (CT) angiography had been suggested as the best therapeutic approach. Dr. Goodman emphasized that the functional and anatomical capabilities of PET scanning provide essential information that clinicians can use to make informed decisions. Dr. Goodman has a variable opinion on the value of social media citing that it can be an excellent tool and source for inspiration, communication, insight, and keeping up to date, however, he encourages students to note that a lot of misinformation is present and that the majority of media sources are not peer reviewed.
To conclude, students learned about Dr. Goodman’s educational and professional history, specifically his training in Internal Medicine and Cardiology at The University of Toronto. Dr. Goodman selected Internal Medicine to keep his options open, but eventually committed to Cardiology which allowed him to pursue his interest in clinical trials. He credits his successes to strong mentors and comments that his favourite part of his job is being a resource, mentor, and educator for the next generation of students.
It was a pleasure to have Dr. Goodman at Medical Grand Rounds. On behalf of the TMED graduate students, we thank him for his time and immense insight into the field of Cardiology.