Perspective:

As an undertone, the study attempts to address whether the presence of ischemia could identify a higher risk group that would potentially benefit from one therapy over another (OMT vs. PCI vs. CABG). There are a number of caveats however that limit deriving strong conclusions from the data. First, the diagnosis of multivessel obstructive disease relied on visual assessment on coronary angiography rather than hemodynamic assessment such as fractional flow reserve; thus, the cohort may represent an overall lower risk group, given the preserved EF and lower prevalence of diabetics. Second, the presence of ischemia was defined as an abnormal EST, which is an insensitive method to assess ischemia, and used here qualitatively rather than quantitatively. Last, as the authors note, the presence of ischemia is not necessarily an indicator of plaque instability, the major factor responsible for clinical events. The ISCHEMIA trial will hopefully provide a definitive answer to whether the severity of ischemia should guide therapy for stable CAD.