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J Am Coll Cardiol. 2016 Jan 5;67(1):81-99. doi: 10.1016/j.jacc.2015.09.056. Epub 2015 Nov 23.

Medical Therapy With Versus Without Revascularization in Stable Patients With Moderate and Severe Ischemia: The Case for Community Equipoise.

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Department of Medicine, Columbia University Medical Center, New York Presbyterian Hospital and the Cardiovascular Research Foundation, New York, New York. Electronic address:
Department of Medicine, Cardiovascular Clinical Research Center, New York University School of Medicine, New York, New York.
Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
Department of Medicine, Samuel S. Stratton VA Medical Center, Albany Medical Center and Albany Medical College, Albany, New York.
Department of Cardiovascular Sciences, East Carolina Heart Institute, East Carolina University, Greenville, North Carolina.
Department of Medicine, Stanford University School of Medicine, Stanford, California.


All patients with stable ischemic heart disease (SIHD) should be managed with guideline-directed medical therapy (GDMT), which reduces progression of atherosclerosis and prevents coronary thrombosis. Revascularization is also indicated in patients with SIHD and progressive or refractory symptoms, despite medical management. Whether a strategy of routine revascularization (with percutaneous coronary intervention or coronary artery bypass graft surgery as appropriate) plus GDMT reduces rates of death or myocardial infarction, or improves quality of life compared to an initial approach of GDMT alone in patients with substantial ischemia is uncertain. Opinions run strongly on both sides, and evidence may be used to support either approach. Careful review of the data demonstrates the limitations of our current knowledge, resulting in a state of community equipoise. The ongoing ISCHEMIA trial (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) is being performed to determine the optimal approach to managing patients with SIHD, moderate-to-severe ischemia, and symptoms that can be controlled medically. (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches [ISCHEMIA]; NCT01471522).


angina pectoris; coronary artery bypass; coronary artery disease; guideline-directed medical therapy; percutaneous coronary intervention

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