Stable Ischemic Heart Disease: Medical Therapy With or Without Revascularization

Coronary artery disease (CAD) poses a significant global public health burden. Patients with CAD who do not present with acute coronary syndromes are considered to have stable ischemic heart disease (SIHD). Options for the management of SIHD are medical therapy including pharmacologic therapy and lifestyle modification and revascularization with either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). Guideline-directed medical therapy is recommended for all patients with SIHD. Aside from severe stenosis in an unprotected left main coronary artery, the role of routine revascularization in the management of SIHD is unclear. Early CABG trials from the 1970s and 1980s demonstrated prognostic benefit with CABG versus medical therapy, but these results have limited applicability in the setting of modern medical therapy, including the widespread use of statins and aspirin and intensive lifestyle interventions. Contemporary strategy trials examining PCI plus medical therapy versus medical therapy alone have not demonstrated prognostic benefit with the addition of PCI. The addition of revascularization offers consistent symptom and quality-of-life benefit compared with medical therapy alone based on trial data, though this benefit may be time limited with PCI. Thus, there is a state of equipoise regarding the addition of revascularization to guideline-directed medical therapy in the management of SIHD. Therefore, shared decision-making is key when determining the best management strategy for a patient with SIHD and should include discussion of expected risks and benefits based on high-quality evidence, costs, and patient preferences. This review contains 6 figures, 8 tables, and 55 references.  Key Words: angina, antianginal therapy, coronary artery disease, coronary artery bypass grafting, guideline-directed medical therapy, ischemia, optimal medical therapy, percutaneous coronary intervention, revascularization