To stent or not to stent? Treating angina after ISCHEMIA—the impact of the ISCHEMIA trial on the indications for angiography and revascularization in patients with stable coronary artery disease

Trials of the indications for revascularization have a long history dating back to the publication of the Veterans Affairs (VA) cooperative study of surgical vs. medical therapy for left main coronary disease.5 Since that time, a considerable body of evidence has been acquired, albeit far from perfect, but notwithstanding, this has been the basis for most of our societal guidelines on the management of stable angina. Nonetheless, it is relevant to highlight the strengths and the limitations of what evidence we have and to clarify the gaps in our knowledge base that were the impetus and, in fact, the rationale for the ISCHEMIA trial. The early trials of coronary bypass surgery vs. medical therapy in patients with stable coronary artery disease had major limitations in terms of their relatively small sample size, lack of use of the internal mammary artery in the majority, and all...