Mounting Evidence for Lack of PCI Benefit in Stable Ischemic Heart Disease:What More Will It Take to Turn the Tide of Treatment?Comment on "Initial Coronary Stent Implantation With Medical Therapy vs Medical Therapy Alone for Stable Coronary Artery Disease"

When treating patients with symptomatic coronary artery disease (CAD), clinicians frequently consider whether the initial management approach should be optimal medical therapy (OMT) alone or OMT in addition to coronary revascularization—generally percutaneous coronary intervention (PCI) in the vast majority of patients for whom revascularization would be considered. Over the past several years, several trials such as the Clinical Outcomes Utilizing Revascularization and Aggressive drug Evaluation (COURAGE) Trial,¹ Bypass Angioplasty Revascularization 2 Diabetes Trial (BARI-2D),² and Japan Stable Angina Pectoris (JSAP) study³ have challenged the conventional wisdom that the triad of angina, objective evidence of myocardial ischemia, and the presence of 1 or more flow-limiting coronary stenoses necessitating revascularization are the sine qua non of optimal CAD management. In the aggregate, these studies have failed to show any incremental clinical benefit for PCI above and beyond OMT for the reduction of death or nonfatal myocardial infarction (MI), findings quite in contrast to those achieved with PCI in acute MI or high-risk patients with acute coronary syndrome (ACS).