‘Vaccination’ against myocardial infarction: the hidden long-term effect of coronary artery bypass grafting

In the field of invasive treatment of coronary artery disease (CAD), the past two decades have been characterised by the conviction that patients with inducible ischaemia benefit from invasively addressing flow-relevant coronary obstructions either by coronary artery bypass grafting (CABG) or by percutaneous coronary intervention (PCI). A plethora of investigations was performed in search of symptom-reducing and life-prolonging effects, and an at-times fierce competition between PCI and CABG arose, with resulting guidelines giving more guidance either towards PCI or towards CABG.1 All these investigations considered both PCI and CABG as revascularisation, presumably because both strategies affect (improve/normalise/restore) coronary blood supply. The most recent ischaemia trial then tested an invasive diagnostic and treatment strategy (where both PCI and CABG were used to provide ‘revascularisation’) against a conservative, non-invasive strategy in patients with chronic CAD who had documented inducible ischaemia.2 The lack of a prognostic impact of the invasive strategy in this setting was sobering to the community, and the results currently question the value of revascularisation in chronic CAD altogether.2