Evaluation of the stable coronary artery disease patient: anatomy trumps physiology

The past decade has been associated with profound progress in both the assessment and treatment of stable ischemic heart disease (SIHD) patients. The many randomized clinical trials, observational studies, and post hoc analyses continue to elucidate the role of coronary anatomy and ischemic burden in treating our patients in routine clinical practice, with the preponderance of the current scientific evidence base suggesting that coronary anatomy does indeed trump physiology in predicting future coronary events in SIHD patients. However, the many clinical studies and post hoc analyses, while provocative, are relatively underpowered; therefore, an important question remains as to whether anatomic burden or ischemic burden can most reliably identify patients who would derive clinical benefits from an initial invasive strategy, regardless of prognostic value.