Therapeutic Strategies in Patients with Chronic Stable Coronary Artery Disease

In chronic stable angina of mild or moderate severity, there is an ongoing debate as to which treatment strategy should be offered to patients: intense medical drug therapy combined with revascularization if medical therapy fails, or direct coronary angiography in view of immediate revascularization in all patients if feasible, both combined with strict risk factor control and secondary prevention. Findings of two large randomized controlled trials, COURAGE and BARI 2D showed that in selected patients with mild to moderate angina and documented coronary disease by coronary angiography suitable for revascularization, there was no difference in death or myocardial infarction between the two strategies. It remains unclear, however, how these findings can be generalized to the broader spectrum of patients with unknown coronary anatomy. This review describes both treatment strategies, their strengths and limitations, and stresses the importance of the documentation of the extent of myocardial ischemia in risk stratifying such patients. Based on the available trial evidence, an algorithm is proposed how to tailor the management strategy to each patient's individual situation.