In this editorial published in the New England Journal of Medicine, the authors remind us that currently, the preferred approach to the management of chronic coronary syndrome is not well defined. There are two strategies: a conservative one and an invasive one. The conservative strategy focuses on guideline-based medical therapy, including antianginal drugs and disease-modifying agents. The invasive strategy adds more to this guideline-based medical therapy, with coronary angiography, followed by either percutaneous coronary intervention or coronary-artery bypass grafting.
Although there is some uncertainty regarding the interpretation of the ISCHEMIA trial results, the invasive strategy does not appear to be associated with clinically meaningful differences in outcomes during 4 years of follow-up. Take-home message: provided there is strict adherence to guideline-based medical therapy, “patients with stable ischaemic heart disease who fit the profile of those in the ISCHEMIA trial and do not have unacceptable levels of angina can be treated with an initial conservative strategy.