[After the ISCHEMIA trial and the new guidelines, does it still make sense to search for myocardial ischemia? When should a patient with chronic coronary syndrome be revascularized?]

The ISCHEMIA study enrolled patients with chronic coronary syndrome, moderate-to-severe myocardial ischemia, and critical coronary stenosis, demonstrating that coronary revascularization is not superior to optimized medical therapy in a population with LDL cholesterol <70 mg/dl in both treatment groups. Despite its bias, ISCHEMIA was able to demonstrate the limitations of a strategy based on coronary revascularization in this clinical setting. Five years after its publication, after even studies based on coronary anatomy have failed to identify a population that benefits from an interventional strategy, coronary revascularization remains the first choice in unstable or worsening angina, in individuals with left main stem disease, complex three-vessel disease, and two-vessel disease with involvement of the proximal anterior interventricular branch or in subjects in whom the objective is to control angina symptoms. In all other cases, medical therapy aimed at achieving lesion stabilization should be preferred. The time has come to promote a critical reflection and question the still dominant practice of performing coronary revascularization directly during coronary angiography based solely on anatomical considerations.