In this clinical discussion, WE Boden and GBJ Mancini, describe a clinical scenario of a physically active man with stable Coronary Artery Disease (CAD). The patient was largely asymptomatic with only occasional symptoms of presumed angina at a high workload. He was faced with making a difficult choice of proceeding with either urgent coronary artery bypass graft surgery within 24 hours or his usual approach of self-informing before making important decisions.
For WE Boden and GBJ Mancini, the core message of ISCHEMIA is that optimal medical therapy is a safe and effective initial management strategy, even in stable patients with extensive CAD and moderate-severe ischaemia.
This information has to be appreciated in the current context in which shared clinical decision-making is increasingly encouraged as an approach to empower patients to participate more knowledgeably in their treatment decisions. Take-home message: a conservative approach may obviate the need for revascularisation in the majority of patiens, while reserving revascularisation in the minority with symptoms or quality of life that are unacceptable on optimal medical therapy. The latest evidence-based information should be explained and discussed with patients.