Stable coronary artery disease: medical therapy versus percutaneous coronary intervention versus surgery

Coronary artery disease (CAD) represents a wide spectrum of underlying anatomical disease ranging from near normal, minor single-vessel disease (SVD), to extensive triple-vessel disease. Its presentation is similarly variable, from a single episode of chest pain to acute coronary syndrome (ACS) or even death. The aim of treatment in CAD is to relieve symptoms and improve quality of life, reduce cardiovascular (CV) events, and prolong survival. There have been vast improvements in management over the years, following a greater understanding of the underlying pathophysiology, the identification and appropriate management of risk factors, development of new medication, and advances in revascularization techniques, both percutaneous and surgical. These developments have resulted in a move towards an anatomic treatment for CAD even though it is the minor lesion, so-called vulnerable plaque, which is suggested as the most likely culprit for mortality. Nevertheless, in those patients presenting with ACS or ST-elevation myocardial infarction the long-term benefits of percutaneous coronary intervention (PCI) have been confirmed in multiple randomized trials; however, debate surrounds the ideal management of the majority of patients who have angina, and who have not experienced any previous CV events or had an interventional procedure, so-called stable CAD.