Functional imaging after the “ISCHEMIA” trial

[Display omitted] •The ISCHEMIA trial compared GDMT with GDMT plus an invasive strategy.•ISCHEMIA patients had SIHD confirmed on CCTA and moderate-severe ischaemia.•ISCHEMIA was not designed to compare different stress testing modalities.•ISCHEMIA was not designed to compare functional testing with anatomical CCTA.•ISCHEMIA was not designed to evaluate the utility of stress testing.•Stress testing was mandatory and part of the inclusion criteria in all patients.•ISCHEMIA did not assess outcomes as a function of ischaemia testing.•Results should not be extrapolated to the role of stress testing in SIHD.•ISCHEMIA was limited to a minority of all-comers with moderate-severe ischaemia.•Moderate-severe ischaemia was assessed by functional testing.•Functional imaging was performed in all participants for inclusion in the trial. Previous randomized trials have shown a lack of benefits from the addition of revascularization to optimal medical therapy versus optimal medical therapy alone in patients with stable ischaemic heart disease at relatively low risk (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation [COURAGE]), and in diabetic patients with stable ischaemic heart disease (Bypass Angioplasty Revascularization Investigation in Type 2 Diabetics [BARI 2D]). More recently, the International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) randomized clinical trial showed similar results in patients with moderate-severe ischaemia on functional testing (imaging or stress electrocardiogram) and at least one significant (> 50%) coronary stenosis in a major epicardial coronary artery on coronarography computed coronary angiography. Although the ISCHEMIA trial adds pivotal knowledge regarding the management of and decision-making in stable patients, this study has prompted a great debate about the role of functional imaging for diagnosis, risk stratification and therapeutic decision-making. The objectives of this review are to summarize the results of the ISCHEMIA trial, to underline its limitations and to warn care providers about potential misinterpretation of this trial.