Mesnier J, Ducrocq G, Danchin N, et al. - Summarized by David L. Brown, MD

This important paper reiterates what has been demonstrated in previous RCTs including COURAGE and ISCHEMIA-improved angina status over time in the medical arm and incomplete relief of angina in the early revascularization arm. These findings suggest that epicardial or microvascular adaptations are more important for angina relief than epicardial revascularization alone. It is assumed but unproven that optimal medical therapy (OMT) is at least partially responsible for these adaptations. Alternatively, since angina regression was reported before the current era of PCI and OMT were available, the natural history of stable angina may include spontaneous remission regardless of the institution of medical therapy. Of the ~33,000 patients in the CLARIFY registry, ~25,000 (78%) were asymptomatic at baseline and < 5% developed angina annually. Thus, most patients with stable angina have no symptoms at baseline and those with angina are likely to have their symptoms resolve over time without revascularization. These findings strongly support a conservative approach to treatment of stable CAD.