EARLY attainment and maintenance of guideline-directed medical therapy (GDMT) goals, particularly blood pressure control, are associated with significantly fewer cardiovascular (CV) events in patients with chronic coronary disease, according to an analysis of 5,179 participants in the ISCHEMIA trial.
Guideline-directed medical therapy, which includes targets for blood pressure, cholesterol, smoking cessation, and antiplatelet use, is recommended for managing chronic coronary disease, yet full adherence remains low. This observational study within the ISCHEMIA trial evaluated how achieving GDMT goals—systolic blood pressure (SBP) <130 mm Hg, LDL cholesterol <70 mg/dL, non-smoking status, and antiplatelet therapy—impacts CV outcomes. Using Bayesian joint modelling, researchers analysed longitudinal goal attainment and its relationship with CV death or myocardial infarction (MI) over four years.
At baseline, only 12% of participants met all four GDMT goals, while 9% met none. Those achieving all goals at baseline and maintaining them had a 4-year CV death/MI rate of 8.7% (95% CrI: 6.7%–10.9%), compared to 24.5% (95% CrI: 13.5%–42.2%) for those meeting no goals. SBP control had the strongest association with risk reduction: achieving the SBP goal resulted in an absolute 5.1% reduction in CV death/MI (95% CrI: –11.3% to –1.0%). A 10 mm Hg lower SBP during follow-up correlated with a 10% relative risk reduction (RR=0.90; 95% CrI: 0.82–0.98). Antiplatelet therapy showed a non-significant trend (–11.2%; 95% CrI: –29.1% to 0.8%), while LDL and smoking cessation had minimal impact. Participants attaining all four GDMT goals at baseline experienced 16% fewer CV events than those meeting none.
These findings highlight the critical need for early and sustained GDMT implementation in clinical practice, prioritising blood pressure management. Clinicians should focus on aggressive SBP control alongside antiplatelet therapy to mitigate CV risks. Future research should explore strategies to improve GDMT adherence and assess whether earlier goal attainment further enhances outcomes.
Reference
Maron DJ et al. Guideline-directed medical therapy and outcomes in the ISCHEMIA trial. JACC. 2025;85 (12) 1317-31.
