To stent or not to stent? Treating angina after ISCHEMIA—why a conservative approach with optimal medical therapy is the preferred initial management strategy for chronic coronary syndromes: insights from the ISCHEMIA trial

Whether percutaneous coronary intervention (PCI) when added to optimal medical therapy (OMT) improves clinical outcomes in patients with chronic coronary syndromes (CCS) has been a continuing area of investigation for more than two decades. While myocardial revascularization, principally with PCI, has been the standard of care for patients with acute coronary syndromes because it improves survival and reduces recurrent myocardial infarction (MI),1,2 its role in patients with CCS is less clear.2,3 Although several randomized clinical trials (RCTs) and meta-analyses indicate that OMT with PCI more effectively relieves angina, decreases the use of anti-anginal medications, and improves functional status and quality of life compared to OMT alone, none of these trials have demonstrated convincingly that an initial strategy of OMT + PCI improves ‘hard’ outcomes, including all-cause and cardiovascular mortality and MI during long-term follow-up.4–12 The recently reported results of the ISCHEMIA trial,13...