Revascularization in stable coronary disease: evidence and uncertainties

Although revascularization has been one of the primary treatment options for obstructive coronary artery disease (CAD) for about 50 years, the evidence base for its use is most robust in the area of acute coronary disease. By contrast, evidence - particularly from clinical trials - supporting the use of revascularization to improve clinical outcomes in stable CAD is in some important respects outdated in that it reflects therapies that predate both contemporary standards for optimal medical therapy and current revascularization techniques and technologies. Despite such limitations, these clinical trials still provide the foundation for many of the current guideline-based indications for coronary revascularization in patients with stable CAD. In this Review, we discuss the major factors underlying the clinical decision to perform revascularization in patients with stable CAD and examine the use and limitations of existing evidence on the choice for, and preferred methods of, revascularization, namely, CABG surgery versus percutaneous coronary intervention.