Treatment of Patients With Stable Ischemic Heart Disease

To the Editor In a recent issue of JAMA, 2 articles differed on the correct treatment of patients with stable ischemic heart disease. In a Viewpoint on evidence-based management of stable ischemic heart disease, Dr Bangalore and colleagues reviewed evidence showing that coronary revascularization was not associated with a reduction in death, myocardial infarction, unplanned revascularization, or angina compared with medical therapy alone and recommended that revascularization should not be performed as first-line treatment in most stable patients. However, Drs Polonsky and Blankstein, in a JAMA Diagnostic Test Interpretation, presented a case of a 53-year-old man with mild angina after running more than 2 miles, with no other symptoms. He underwent an exercise treadmill test (ETT), which showed excellent functional capacity, absence of chest pain, and a Duke Treadmill Score of 5.5 (low risk [ie, <1% mortality/year]). Despite stable disease, mild symptoms, excellent exercise capacity, and low risk, the patient underwent a coronary angiogram and subsequent coronary artery bypass graft (CABG) surgery. Hence, his treatment appears to contradict that recommended by Bangalore et al. Inappropriate coronary revascularization is a problem worldwide, and although recent years have seen improvement, it still represents a high percentage of all revascularization procedures. Contradictory messages may contribute to this important problem.

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