Reasonable Incomplete Revascularization and the Role for Adjunct Medical Therapy in Ischemic Heart Disease

The goal of complete revascularization in multivessel coronary artery disease is the elimination of all ischemia-producing lesions, either through coronary artery bypass grafting or percutaneous coronary intervention. However, a substantial proportion of patients receiving contemporary revascularization undergo incomplete revascularization, often with residual ischemia. Currently, the decision of whether to pursue a complete or a limited revascularization strategy is determined by the interventional cardiologist, often in consultation with referring physicians and taking into consideration patient preference. Although there are no guideline-specific recommendations regarding completeness of revascularization, there are passionate arguments supporting the value of complete revascularization by some and the equivalence of incomplete revascularization by others. This article focuses on the evidence that underlies the controversy regarding completeness of revascularization. When interpreting current evidence in patients with multivessel coronary artery disease, decision making regarding treatment strategy should take into account four concepts: (1) incomplete revascularization is more common in clinical practice than complete revascularization; (2) the definition of incomplete revascularization is not uniform; (3) completeness of revascularization is not always superior to incomplete revascularization; and (4) all incomplete revascularization scenarios are not equivalent. We believe that a reasonable incomplete revascularization strategy needs to include a consideration of adjunctive anti-ischemic medications (in particular effective anti-ischemic therapies such as ranolazine), and active monitoring of its effectiveness in reducing residual ischemia.