Skip to main content
Dr. Shaun Goodman

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.

Comments

Name
Caitlyn Vlasschaert

Mon, 10/05/2020 - 11:45

Thank you Dr. Goodman for bringing two of this year's biggest trials– ISCHEMIA and ISCHEMIA-CKD– to Queen's MGR. Thank you also to Jordan for leading the Q&A and summarizing the presentation so well.

CKD patients are often excluded from clinical trials, and as a result, it's not always clear whether the benefits of a studied intervention extend to this population. When it comes to cardiac catheterization, concern regarding contrast-associated AKI and permanent kidney damage can drive higher rates of "conservative care" (i.e., no cath) in this population. Indeed: a 2004 study showed that CKD patients underwent the procedure only half as often and had double the mortality as patients with intact GFR (https://pubmed.ncbi.nlm.nih.gov/15339996/). This is an example of "renalism"– suboptimal care as a result of lack of data regarding safety/efficacy in this population.

The ISCHEMIA trial team, including Dr. Goodman, raised the bar when it comes to CKD patient inclusion. They devised an adapted protocol and ran a separate trial, ISCHEMIA-CKD, to study their intervention in patients with eGFR <30. This was very exciting for the kidney world! The online nephrology community (#NephTwitter) even hosted a big online journal club to discuss its results (http://www.nephjc.com/news/ischemiackd). A big step forward in addressing renalism.

Name
Caitlyn Vlasschaert

Name
Melinda Chelva

Mon, 10/05/2020 - 13:00

Excellent post Jordan! You eloquently summarized all the topics Dr. Goodman covered during the MGR and the facilitated discussion last week.

As you mentioned, we covered a variety of topics during the discussion. I was particularly interested to learn about the gender based differences in cardiovascular disease, and the under-representation of women in several studies. The MGR last week left me wondering what impact age AND gender have on determining whether the invasive or conservative approach is taken? I wonder whether this will be a future direction of study?

Similarly, Dr. Goodman highlighted which tests (e.g. Seattle Angina Questionnaire) have been used to assess the quality of life of patients who undergo either the conservative or invasive treatment. I wonder why this test was chosen over other qualitative questionnaires that evaluate patients with cardiovascular disease? I wonder if it is because this test provides a more comprehensive assessment/evaluates specific outcomes regarding the quality of life of patients, that other tests can’t achieve?

In summary, it was a pleasure to hear from Dr. Goodman last week! He is an excellent speaker! His passion for his work and interest to motivate young researchers is very clear! I’m thankful to have had the opportunity to hear his insight regarding coronary artery disease management, and I’m looking forward to following his research in the years to come.

Name
Melinda Chelva

Name
Kassandra Coyle

Mon, 10/05/2020 - 14:29

Thank you, Dr. Goodman, for this enlightening talk and thank you Jordan for the wonderful summary.

Dr. Goodman shared with us an interesting set of results looking at the cumulative index of the primary composite outcome of death from cardiovascular causes after both the invasive and conservative strategy approaches. It was interesting to see that the invasive strategy group was reported with an initial hazard of increased risk of primary outcome. However, the 2 curves crossed over after approximately 2 years, with the conservative group having a higher estimated rate of primary outcome compared to the invasive strategy group. This study showed results up to 5 years after treatment, and although the results were not statistically significant, it appeared as though they were differentiating over time. It will be interesting to watch this trend, as the 2 strategies continue to advance to see if there is further separation of the risk of primary outcomes between the 2 groups. If this is the case I am curious to find out if there will be a change in the gold standard of treatment in the future.

During our discussion with Dr. Goodman, he mentioned that the choice between which approach used, often depends on the physician’s opinion of what is better. He provided us with an example of a study that looked at different treatment methods used for hypertensive patients. In this study, they found that the determination of what treatment a patient was given depended upon what year the physician had graduated medical school. I thought this was interesting as it shows that even with all the advancements in research there is still a tendency to stick with one’s initial bias.

Name
Kassandra Coyle

Name
Jummy Oladipo

Mon, 10/05/2020 - 15:34

Thank you, Dr. Goodman, for speaking with us and thank you, Jordan for a very detailed summary of the discussion.

I really enjoyed learning more about the ISCHEMIA trial. It is interesting that between the two types of interventions (invasive vs. conservative approach) there seems to be no significant differences in the rates of death from cardiovascular-related causes. The conclusions from this trial really emphasize the importance of physicians having thorough conversations with their patients to come to the best decision for that patient. With the challenges and fear that COVID-19 presents, I am wondering if there is a slight bias for physicians to prefer the conservative approach if it is possible during these times. Since there appears to not be a significant difference in outcomes, would this potentially make physicians favour this method over the invasive one to decrease the number of elective surgeries being done? I am very interested to see what the results are for the next trial they are hoping to perform that will be looking at the long-term outcomes of the interventions.

Name
Jummy Oladipo

Name
Charmi Shah

Mon, 10/05/2020 - 18:46

Thank you Dr. Goodman for the engaging presentation, and Jordan for the excellent facilitation and summary.

I was very intrigued by the implications of the results from the poll that Dr. Goodman conducted. The poll was a great way to open the conversation about the division in the utilization of current treatments for ischemic heart disease, in terms of invasive and conservative treatment approaches. Yet, this lack of consensus among healthcare providers in deciding the best treatment approach is present in nearly every specialty. This division does not seem to be due to a lack of research regarding treatment options because the research is abundant and ever-growing, but it may be because navigating through the ample research and translating it to the field is complicated. Along with this, what "best care" means for each patient is different and the same treatments can lead to dissimilar outcomes for different patients. With this immense complexity, it makes me wonder what the best way might be to translate research regarding treatment options for healthcare providers?

Dr. Goodman also raised the question of the long term benefits of the invasive approach for the participants in the ISCHEMIA trial. It will be interesting to see whether there are benefits or not for the invasive approach once the results from the extended follow-up period are collected and examined. I look forward to learning what is discovered in these results.

Name
Charmi Shah

Name
Max Moloney

Wed, 10/07/2020 - 11:35

Thank you, Jordan for your detailed summary of Dr. Goodman’s presentation during Medical Grand Rounds last Thursday.

Dr. Goodman’s work in the ISCHEMIA trails highlights the importance of translating peer-reviewed research findings into clinical practice. As Dr. Goodman mentioned during his discussion, once a physician has completed their medical education, they are likely to stick to their original bias when selecting between treatment options. This is an important consideration to take into account when thinking critically about how to most effectively translate research from the lab or clinical trials to everyday practice. I am curious to see if there are any discrepancies in the outcomes between the invasive and conservative approaches after the extended follow-up period has completed. I look forward to reading the continuing ISCHEMIA and ISCHEMIA-CKD trials and the work of Dr. Goodman in the future.

Name
Max Moloney

Name
Michaela Spence

Thu, 10/08/2020 - 17:45

Thank you to Dr. Goodman for the wonderful talk and to Jordan for the excellent summary of Dr. Goodman’s presentation!
One of the many things that interested me about this talk was that between the invasive and conservative treatment approaches, there were no significant differences in rate of major adverse cardiac event (MACE) post treatment even though angina symptoms improved. We discussed why “vulnerable” plaque being present and prone to rupture in these patients, may have been the reason why incidence of MACE wasn’t that different between the two treatment groups. As of right now, patients with vulnerable plaque are treated using statins and diet changes. I wonder if as novel therapies for treatment of vulnerable plaque are found, there will be a shift to a more pharmaceutically orientated treatment approach rather than the bias towards surgical intervention seen today if vulnerable plaque truly is the main culprit behind MACE.

Name
Michaela Spence

Add new comment

Plain text

  • No HTML tags allowed.
  • Lines and paragraphs break automatically.
  • Web page addresses and email addresses turn into links automatically.