Significant Left Main Coronary Artery Disease Research Articles

Contemporary State-of-the-Art PCI of Left Main Coronary Artery Disease.

The left main coronary artery (LMCA) supplies over 70% of the myocardium, and significant LMCA disease is associated with high morbidity and mortality. With remarkable advances in percutaneous coronary intervention (PCI), including stent technology, antithrombotic agents, and evolving procedural techniques, PCI has become an important treatment option in clinical practice guidelines for the revascularization of LMCA disease. In contemporary clinical practice, a heart-team approach to shared decision-making, considering clinical/anatomic factors along with patient preferences, is emphasized for patients with significant LMCA disease requiring myocardial revascularization. Furthermore, recent progress in PCI procedures combined with intravascular imaging or functional guidance has resulted in significant improvements in PCI outcomes, especially for complex lesions, including LMCA disease. Nevertheless, owing to inherent anatomic complexities and frequent multivessel involvement, several unmet issues remain regarding the determination of the appropriate treatment approach for significant LMCA disease, for which further clinical research is required. This contemporary review article provides a comprehensive overview of left main PCI based on current guidelines and underlying trial data, addresses important unresolved diagnostic and therapeutic issues, and identifies future perspectives likely to advance progress in this field.

Computed tomography coronary angiography assessment of left main coronary artery stenosis severity

BackgroundAngiographic assessment of left main coronary artery (LMCA) stenosis severity can be unreliable. In cases of ambiguity, intravascular ultrasound (IVUS) can be utilised with a minimal lumen area (MLA) of ≥6 ​mm2 an accepted threshold for safe deferral of revascularization. We sought to assess whether quantitative computer tomography coronary angiography (CTCA) measures could assist clinicians making LMCA revascularization decisions when compared with IVUS as gold standard. MethodsConsecutive patients undergoing IVUS assessment of angiographically intermediate LMCA stenosis were included. All patients had undergone 320-slice CTCA <90 days prior to IVUS imaging. Offline quantitative assessment of IVUS- and CT-derived measures were undertaken with the cohort divided into those with significant (s-LMCA) versus non-significant (ns-LMCA) disease using the accepted IVUS threshold. ResultsFifty-eight patients were included, with no difference in mean age (61.5 ​± ​12.2 vs. 59.7 ​± ​11.9 years, p ​= ​0.57), diabetic status (24.2% vs 16.0%, p ​= ​0.44) or other baseline demographics between groups. Patients with ns-LMCA had larger CT luminal area (8.64 ​± ​3.91 vs. 5.41 ​± ​1.54 ​mm2, p ​< ​0.001), larger minimal lumen diameter (MLD) (3.25 ​± ​0.74 vs. 2.56 ​± ​0.38 ​mm, p ​< ​0.001) and lower area stenosis (45.74 ​± ​18.10 vs. 60.93 ​± ​14.68%, p ​= ​0.001). There was a significant positive correlation between CTCA and IVUS MLA (r ​= ​0.68, p ​< ​0.001) and MLD (r ​= ​0.67, p ​< ​0.001). ROC analysis demonstrated CTCA MLA cut-off <8.29 ​mm2 provides the greatest negative predictive value and sensitivity in predicting the presence of significant LMCA disease. ConclusionCTCA derived MLA and MLD have a strong correlation with IVUS. A CTCA derived MLA cut-off <8.29 ​mm2 showed greatest clinical utility for predicting the need for further assessment, based on IVUS gold standard.

Gender differences in clinical characteristics, angiographic profile, and outcomes of left main coronary artery disease

Context: Left main coronary artery (LMCA) disease is associated with high morbidity and mortality in spite of advances in management. There is a paucity of data on the gender differences in LMCA disease. Aims: We aimed to study the clinical characteristics, angiographic profile, and outcome of coronary artery disease patients with significant LMCA disease. Settings and Design: This is a prospective observational study among patients with significant LMCA disease undergoing coronary angiography in a tertiary care center. Subjects and Methods: We compared clinical, angiographic characteristics among male and female patients with significant LMCA disease and followed up for 4 months. Statistical Analysis Used: Differences between the groups were compared with Student’s t-test for parametric continuous variables. Chi-square test was applied for estimating the occurrence of categorical variables. Pearson’s correlation coefficient was used to test the relationship between parameters. Results: Among 100 consecutive patients with LMCA disease, 70 were males and 30 were females. Chronic stable angina was the most common presentation. Distal LMCA was the most common site. Isolated LMCA disease was less compared to LMCA + multivessel disease. Coronary artery bypass grafting was the predominant management strategy. Mortality rates at 6 months were higher in females compared to males (20% vs. 3.3%). Conclusions: LMCA disease has mostly similar angiographic and clinical characteristics among males and females. LMCA disease is associated with high mortality in females compared to males.

Management of patients with left main stem stenosis in Iceland 2010–2020: PCI or CABG?

Abstract Introduction Coronary artery bypass surgery (CABG) has been standard treatment for patients with left main coronary artery disease (LMCAD) but percutaneous coronary intervention (PCI) is a good alternative in selected patients. Our purpose was to evaluate the prevalence of LMCAD in Iceland, the impact of background factors on treatment choices, and treatment changes in recent years with respect to current guidelines. Methods This retrospective, population-based study analyzed data from the SCAAR-SWEDEHEART database. Patients with significant LMCAD on coronary angiography in Iceland 2010–2020, without previous history of CABG or contraindication for surgery were enrolled. Survival analysis was estimated with Kaplan-Meier and COX regression analysis for investigating the association between survival time and predictor variables. Findings Of 702 patients with LMCAD, 195 were treated with PCI, 460 with CABG and 47 with medical treatment only. The widest age range was in the PCI group and the mean age was highest in the medical therapy only group (p&amp;lt;0.001). Patients with LMCAD and either three vessel disease or heart valve disease were most often treated with CABG (76.1% and 84.4%, p&amp;lt;0.001).The majority of patients with LMCAD only were treated with PCI, as were patients with STEMI or cardiogenic shock (67.1% and 70.0%, p&amp;lt;0.001). The proportion of patients treated with PCI increased from 19.8% in 2010–2015 to 42.7% in 2016–2020. There was no significant difference in survival between PCI and CABG (p=0.41). Conclusions In patients with LMCAD the main factors that affect treatment choice are age, anatomical complexity and acuteness. Treatment choice appears to be in keeping with current guidelines. There is no significant difference in long term survival between PCI and CABG groups but the groups are different. There has been a significant increase in patients treated with PCI in recent years. Funding Acknowledgement Type of funding sources: None.

Management of patients with left main stem stenosis in Iceland 2010-2020: PCI or CABG

Coronary artery bypass surgery (CABG) has been standard treatment for patients with left main coronary artery disease (LMCAD) but percutaneous coronary intervention (PCI) can be a good alternative. Our aim was to evaluate revascularization of LMCAD-patients in Iceland and treatment changes in recent years. We also assessed the impact of patient background factors on treatment choice and long-term survival. This retrospective, population-based registry-study analyzed data from the SCAAR-SWEDEHEART database. Patients with significant LMCAD on coronary angiography in Iceland 2010-2020, without previous history of CABG or contraindication for surgery were enrolled. The Kaplan-Meier method was used to study long-term survival and COX-regression analysis to adjust for predictor variables. Of 702 LMCAD patients, 195 were treated with PCI, 460 with CABG and 47 with medical therapy. The widest age-range was in the PCI group and the mean age was highest in the medical therapy group. Patients with LMCAD and concomitant three vessel disease or heart valve disese were mostly treated with CABG (76.1% and 84.4%). The majority of patients with LMCAD only were treated with PCI, as well as patients presenting with STEMI or in cardiogenic shock (67.1% and 70.0%). The proportion of patients treated with PCI increased from 19.8% in 2010-2015 to 42.7% in 2016-2020. There was no significant difference in survival between the PCI and CABG-groups (p=0.41). In patients with LMCAD the main factors determining treatment choice are age, anatomical complexity and acuteness. There has been a significant increase in LMCAD patients treated with PCI.

Impact of Coronary Chronic Total Occlusion on Long-term Clinical Outcome in Patients with Unprotected Left Main Disease Undergoing Percutaneous Coronary Intervention

Objectives: Reported data regarding the prevalence, prognostic impact, and safety and efficacy of revascularization of coronary chronic total occlusion (CTO) in patients with left main coronary artery (LMCA) disease who undergo percutaneous coronary intervention (PCI) are scarce. The aim of the present study was to compare clinical outcomes among patients with LMCA disease undergoing PCI. Outcomes were compared between those with and without coronary CTO and between those with CTO who had successful and unsuccessful CTO recanalization procedures. Methods: All consecutive patients with significant LMCA disease (&gt;50% stenosis at coronary angiography) who underwent PCI between July 2014 and December 2018 were retrospectively included in our study. The primary endpoint of the study was long-term mortality. Secondary endpoints included the incidence of myocardial infarction, repeat percutaneous or surgical revascularization, stroke, and stent thrombosis. Results: Between July 2014 and December 2018, 578 patients underwent PCI for LMCA disease at Pederzoli Hospital and University of Turin were enrolled. They were divided into 3 groups: group A: 374 (65%) patients without CTO, group B: 108 (19%) patients with untreated or unsuccessfully treated CTO, and group C: 96 (17%) patients with successfully treated CTO. At a median follow-up of (1090 ± 279) days, there were no statistically significant differences between the groups in terms of the primary and secondary endpoints. However, there was a trend towards higher mortality in patients with untreated or unsuccessfully treated CTO (13% vs. 19% vs. 14% in groups A, B, and C, respectively; P = 0.12). The primary and secondary endpoints were further analyzed based on the presence or absence of myocardial viability: subgroup C1: 54 (56%) patients with successful percutaneous transluminal coronary angioplasty (PTCA) having viability, and subgroup C2: 42 (44%) patients with successful PTCA not having viability. There was a trend toward a statistically significant higher rate of death among patients in group B, who underwent unsuccessful recanalization with viable myocardium (19% vs. 9% vs. 19% in groups B, C1, and C2, respectively, P = 0.05). On multivariable analysis, the propensity for successful revascularization of CTO was associated with a reduced risk of death (P = 0.01; odds ratio, 0.75; 95% confidence interval: 0.62–0.87). Conclusions: Among patients with LMCA disease undergoing PCI, CTO represents a common finding associated with worse prognosis. Successful revascularization of CTO in patients with viable myocardium appears to significantly improve prognosis.

Relief of Ischemia in Ischemic Cardiomyopathy

Ischemic heart disease is among the most common causes of morbidity and mortality worldwide. In its stable manifestation, obstructing coronary artery stenoses prevent myocardial blood flow from matching metabolic needs of the heart under exercise conditions, which manifests clinically as dyspnea or chest pain. Prolonged bouts of ischemia may result in permanent myocardial dysfunction, heart failure, and eventually reduced survival. The aim of the present work is to review currently available approaches to provide relief of ischemia in stable coronary artery disease (CAD). Several pharmacological and interventional approaches have proven effectiveness in reducing the burden of ischemia in stable CAD and allow for symptom control and quality of life improvement. However, substantial evidence in favor of improved survival with ischemia relief is lacking, and recently published randomized controlled trial suggests that only selected groups of patients may substantially benefit from this approach. Pharmacological treatments aimed at reducing ischemia were shown to significantly reduce ischemic symptoms but failed to provide prognostic benefit. Myocardial revascularization is able to re-establish adequate coronary artery flow and was shown to improve survival in selected groups of patients, i.e., those with significant left main CAD or severe left ventricular dysfunction in multivessel CAD. Outside the previously mentioned categories, revascularization appears to improve symptoms control over medical therapy, but does not confer prognostic advantage. More studies are needed to elucidate the role of systematic invasive functional testing to identify individuals more likely to benefit from revascularization and to evaluate the prognostic role of chronic total occlusion recanalization.

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Which Intervention for Patients with Left-Main Coronary Artery Disease?

Historically, patients with significant left-main coronary artery disease (CAD) have been managed with coronary-artery bypass grafting (CABG), based on

Left main coronary artery disease: when and how to perform PCI?

Left main coronary artery (LMCA) disease has been reported in up to 10% of all patients with coronary artery disease (CAD) and in the majority of cases are associated with severe three-vessel CAD. Among patients with chronic coronary syndrome revascularization of significant LMCA disease improves prognosis, while there is a debate about which revascularization strategy, CABG surgery or percutaneous coronary interventions to use. We do a review of the available evidence about the impact of LMCA lesions on patient prognosis according to CAD extension and clinical presentation, the outcome after percutaneous or surgical revascularization, the procedural challenges of LMCA PCI and the available armamentarium to optimally treat this relevant population.

Percutaneous Coronary Intervention and Coronary Artery Bypass Grafting for the Treatment of Left Main Coronary Artery Disease.

Severe stenosis of the left main coronary artery (LMCA) generally occurs as a result of atherosclerosis and compromises the blood supply to a wide area of myocardium, thereby increasing the risk of serious adverse cardiac events. Current revascularization strategies for patients with significant LMCA disease include coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI), both of which have a range of advantages and disadvantages. In general, PCI is associated with a lower rate of periprocedural adverse events and provides more rapid recovery, while CABG provides more durable revascularization. Most clinical trials comparing PCI and CABG for the treatment of LMCA disease have shown PCI to be non-inferior to CABG with respect to mortality and the serious composite outcome of death, myocardial infarction, or stroke in patients with low-to-intermediate anatomical complexities. Remarkable advancements in PCI standards, including safer and more effective stents, adjunctive intravascular imaging or physiologic evaluation, and antithrombotic treatment, may have contributed to these favorable results. This review provides an update on the current management of LMCA disease with an emphasis on clinical data and academic and clinical knowledge that supports the use of PCI in an increasing proportion of patients with LMCA disease.

Revascularization of Left Main Coronary Artery

Left main coronary artery (LMCA) disease affect 5-7% of patient undergoing coronary angiography and is associated with multivessel CAD in 70% of the cases. Untreated significant LMCA disease is associated with significant mortality and morbidity. CABG is the traditional therapy for revascularization in LMCA disease. PCI is a reasonable alternative mainly in patients with high surgical risk or other specific factors. Drug-eluting stents, improved antiplatelet therapeutic options, atherectomy techniques, IVUS-guidance and improved operator experience have all contributed to the observed improvement in clinical outcomes. Given the large number of variables involved in deciding between PCI and CABG, a heart team should make decisions regarding revascularization of LMCA disease.

10-Year Outcomes of Stents Versus Coronary Artery Bypass Grafting for Left Main Coronary Artery Disease

BackgroundComparative outcomes of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for left main coronary artery (LMCA) disease were previously reported. However, data on very long-term (>10 years) outcomes are limited. ObjectivesThe authors compare 10-year outcomes after PCI and CABG for LMCA disease. MethodsIn this observational study of the MAIN-COMPARE (Revascularization for Unprotected Left Main Coronary Artery Stenosis: Comparison of Percutaneous Coronary Angioplasty versus Surgical Revascularization) registry, the authors evaluated 2,240 patients with unprotected LMCA disease who underwent PCI (n = 1,102) or underwent CABG (n = 1,138) between January 2000 and June 2006. Adverse outcomes (death; a composite outcome of death, Q-wave myocardial infarction, or stroke; and target-vessel revascularization) were compared with the use of propensity scores and inverse-probability-weighting adjustment. The follow-up was extended to at least 10 years of all patients (median 12.0 years). ResultsIn the overall cohort, there was no significant difference in adjusted risks of death and the composite outcome between the groups up to 10 years. The risk of target-vessel revascularization was significantly higher in the PCI group. In the cohort comparing drug-eluting stents and concurrent CABG, the 2 study groups did not differ significantly in the risks of death and the composite outcome at 5 years. However, after 5 years, drug-eluting stents were associated with higher risks of death (hazard ratio: 1.35; 95% confidence interval: 1.00 to 1.81) and the composite outcome (hazard ratio: 1.46; 95% confidence interval: 1.10 to 1.94) compared with CABG. ConclusionsIn patients with significant LMCA disease, as compared with CABG, PCI showed similar rates of death and serious composite outcomes, but a higher rate of target-vessel revascularization at 10 years. However, CABG showed lower mortality and serious composite outcome rates compared with PCI with drug-eluting stents after 5 years. (Revascularization for Unprotected Left Main Coronary Artery Stenosis: Comparison of Percutaneous Coronary Angioplasty versus Surgical Revascularization [MAIN-COMPARE]; NCT02791412)

Management of Left Main Coronary Artery Disease.

Left main coronary artery disease (LMCAD) portends higher prognostic risk as a result of the large myocardial territory at risk, ranging from 75% to 100%, depending on the dominance of the left coronary circulation. Diagnosis and management of significant LMCAD continues to be a source of clinical

Safety and Effectiveness of Second-Generation Drug-Eluting Stents in Patients With Left Main Coronary Artery Disease

BackgroundLimited data are available on the relative performances between different types of drug-eluting stents (DES) for obstructive left main coronary artery disease (LMCAD). ObjectivesThis study sought to compare effectiveness and safety profiles of various second-generation DES for LMCAD in real-world clinical practice. MethodsAmong 4,470 patients in 3, multicenter, prospective registries (IRIS-DES [Interventional Cardiology Research Incorporation Society-Drug-Eluting Stents] registry, the IRIS-MAIN [Interventional Cardiology Research Incorporation Society-Left MAIN Revascularization] registry, and the PRECOMBAT [PREmier of Randomized COMparison of Bypass Surgery versus AngioplasTy Using Drug-Eluting Stent in Patients with Left Main Coronary Artery Disease] study) treated between July 2007 and July 2015, the authors identified 2,692 patients with significant LMCAD who received second-generation DES; 1,254 with cobalt-chromium everolimus-eluting stents (CoCr-EES), 232 with biodegradable polymer biolimus-eluting stents (BP-BES), 616 with platinum-chromium EES (PtCr-EES), and 590 with Resolute zotarolimus-eluting stent (Re-ZES). The primary outcome was target-vessel failure. ResultsThe observed 3-year rates of target-vessel failure were not significantly different for the different types of DES (16.7% for the CoCr-EES, 13.2% for the BP-BES, 18.7% for the PtCr-EES, and 14.7% for the Re-ZES; p = 0.15). In multiple treatment propensity score analysis, the adjusted hazard ratios (HRs) for target-vessel failure were similar in between-group comparisons of the different DES, except for the PtCr-EES versus the BP-BES (reference; HR: 1.60; 95% confidence interval: 1.01 to 2.54; p = 0.046). There were no significant differences in risk of composite of all-cause death, any myocardial infarction, or any revascularization and its individual components according to the different types of DES. Although the 3-year incidence of stent thrombosis was considerably low (≤1.0%) for all types of DES, between-group differences were observed, generally favoring the EES platforms. ConclusionsIn this pooled analysis of 3 prospective registries involving unrestricted use of various second-generation DES for LMCAD, we found no significant between-group differences in 3-year risk of target-vessel failure, except for a higher risk of primary outcome with PtCr-EES compared to BP-BES. (Evaluation of the First, Second, and New Drug-Eluting Stents in Routine Clinical Practice [IRIS-DES]; NCT01186133)

Findings of Single-Photon Emission Computed Tomography and Its Relation with Quantitative Coronary Angiography in Patients with Significant Stenosis of the Left Main Coronary Artery.

ObjectiveUnrecognized left main coronary artery disease (LMCD) is often fatal; however, accuracy of non-invasive tests for diagnosing LMCD is still unsatisfactory. This study was performed to elucidate single-photon emission computed tomography (SPECT) detection of LMCD using quantitative coronary angiography (QCA) data.Materials and MethodsFifty-five patients (39 men; mean age, 68.1 ± 10.9 years) diagnosed with significant left main (LM) stenosis (≥ 50%) by invasive coronary angiography (ICA) were retrospectively reviewed. All study patients underwent SPECT with pharmacologic stress within 30 days of ICA. All coronary lesions were quantified via QCA, and SPECT findings were compared with QCA results.ResultsOnly four patients (7.3%) had isolated LMCD; all others had combined significant stenosis (≥ 70%) of one or more other epicardial coronary arteries. Patients with more severe coronary artery disease tended to have higher values for summed difference scores in a greater number of regions, but the specific pattern was not clearly defined. Summed stress score of SPECT did not differ according to LM stenosis severity. Only three patients (5.4%) had a typical LM pattern of reversible perfusion defect on SPECT. A significant negative linear correlation between stenosis severity and stress perfusion percent was found in the left anterior descending artery region (r = −0.455, p < 0.001) but not in the left circumflex artery.ConclusionSingle-photon emission computed tomography findings were heterogeneous, not specific and poorly correlated to QCA data in patients with significant LMCD. This may be due to highly prevalent significant stenosis of other epicardial coronary arteries.

Prediction of Significant Left Main Coronary Artery Disease using ST-segment Elevation in aVR Among Adult Patients with Acute Coronary Syndrome Admitted at a Tertiary Hospital from January 2011 through December 2015

Introduction: This study aims to determine whether ST-segment elevation in aVR predicts significant left main coronary artery (LMCA) disease among adult patients with acute coronary syndrome (ACS). Method: This retrospective study enrolled adult patients, aged 18 years and above, who were diagnosed with ACS, have undergone coronary angiogram, with retrievable electrocardiogram tracings, and were admitted at a tertiary hospital from January 1, 2011 through December 31, 2015. Results: A total of 276 patients were included in the study, majority of them were male, and the mean age was 60+12 years. Forty-three patients had significant LMCA disease, 18 with ST-segment elevation in aVR; 24 patients had no significant LMCA involvement, with ST-segment elevation in aVR; and 209 had no significant left main disease and did not show ST-segment elevation in aVR. Conclusion: The study showed that ST-segment elevation of 0.13 mV in aVR has a sensitivity of 92.9%, specificity of 2.1%, likelihood ratio of 0.95, positive predictive value (PPV) of 14.6% and negative predictive value (NPV) of 62.5% in predicting a significant LMCA disease. ST elevation in aVR has high sensitivity but low specificity, LPV and NPV for predicting significant LMCA disease. Keywords: ECG changes in left main coronary artery disease, ST-segment elevation in aVR.

Incidence, predictors, clinical profile, management and outcome of patients with isolated left main coronary artery ostial disease

ObjectivesIsolated left main coronary artery (LMCA) ostial disease is a rare variant of LMCA disease. Earlier studies on this disease are limited by small number of patients enrolled. The aim of the present study was to analyze the incidence, risk factors, clinical profile and long term outcome of patients with isolated LMCA ostial disease. Methods15,553 patients who underwent coronary angiogram in a single tertiary care cardiac hospital were analyzed for LMCA disease. 351(2.2%) patients were found to have significant LMCA disease out of which 28(0.18%) had isolated LMCA ostial disease. These 28 patients were compared with 323 non-ostial and non-isolated LMCA disease patients. ResultsThe mean age of isolated LMCA ostial disease group was significantly less than the other group (p=0.009). Females were more affected than males (p=0.008). They also had low incidence of coronary risk factors (especially dyslipidemia, p=0.04). They tend to present more with stable angina and less with myocardial infarction. They had higher ejection fraction and normal regional wall motion (p=0.04). There was no mortality difference between two groups at the end of 1 year (p=0.234). ConclusionIn one of the largest studies done in these patients, we found that isolated LMCA ostial disease is more common in middle aged females with few coronary risk factors. These patients also had a better ejection fraction and normal regional wall motion compared to patients with non-ostial and non-isolated LMCA disease. The clinical and angiographic profile of these patients suggests that they may represent a distinct clinical entity.

Medical angioplasty for iatrogenic malignant coronary atherosclerosis

The prevalence of coronary artery disease has drastically increased worldwide. The current guidelines recommend optimized medical therapy as the first-line treatment for stable angina; with revascularization reserved for those whose symptoms persist or progress despite intensive medical therapy. However, in the present world, many patients undergo revascularization as the first-line treatment, despite these recommendations. We report the case of a young obese female with stable angina, who underwent percutaneous coronary intervention for single vessel disease. Her symptoms aggravated post-procedure and was later found to have a lesion in the left main coronary artery (LMCA) causing 80% stenosis. In view of significant LMCA disease, she was advised revascularization but was not willing for the same. Hence, she was treated with optimal medical therapy and therapeutic lifestyle changes, which completely resolved her symptoms.

Does ischemia burden in stable coronary artery disease effectively identify revascularization candidates? Ischemia burden in stable coronary artery disease does not effectively identify revascularization candidates.

Over 30 years ago, a benefit of surgical revascularization was demonstrated in patients with stable ischemic heart disease (SIHD) but this was before most of our current disease-modifying medical therapies for coronary artery disease (CAD) were available.1 Analysis of these trials indicated that patients who derived the most benefit from surgery were those with more extensive CAD, particularly those with significant left main CAD or multivessel CAD, including proximal left anterior descending stenosis. After the introduction of percutaneous coronary intervention (PCI), studies were performed in the 1990s comparing PCI with contemporary medical therapy and found no benefit on death, myocardial infarction, or revascularization.2 It was at the time unclear whether this was because of the different revascularization technique or advances in medical therapy. See Response by Hachamovitch Subsequently, 2 large, randomized, multicenter trials were undertaken to determine whether revascularization offered an advantage over intensive medical therapy (optimal medical therapy). The Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) and Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI-2D) trials randomized patients with SIHD to a strategy of routine revascularization in addition to optimal medical therapy or to a strategy of optimal medical therapy alone.3,4 The optimal medical therapy approach included statin-based lipid-lowering therapy with a target low-density lipoprotein 60 to 85 mg/dL, anti-ischemic medications alone or in combination, and angiotensin-converting enzyme inhibition or angiotensin receptor blockade. The COURAGE trial included 2287 patients and used PCI as the revascularization technique. There was no benefit on the primary end point of death or myocardial infarction (MI) for the routine PCI strategy over a median 4.6 years of follow-up and there was also no difference between groups in survival. The BARI-2D trial included 2368 patients with diabetes mellitus and both PCI and surgery were used for revascularization. Randomization was …