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Patients with mild, exertional angina and their physicians routinely face the decision of whether to pursue a conservative strategy of guideline-directed medical therapy (GDMT) versus an invasive strategy of diagnostic cardiac catheterization (cath) and revascularization plus GDMT. Recent randomized clinical trials with stable ischemic heart disease (SIHD) patients comparing a conservative versus revascularization strategy have demonstrated no difference in major clinical events, but these trials randomized patients after performing cath and knowing coronary anatomy.This issue of Controversies in Interventional Cardiology addresses the following statement: “In mildly symptomatic patients, should an invasive strategy with catheterization and revascularization be routinely undertaken?” The authors presenting the pro and con positions have agreed on the following assumptions: (1) the patient has been diagnosed recently with SIHD on the basis of a stress test performed for typical symptoms; (2) the stress test did not demonstrate high-risk features to suggest significant left main disease; (3) the diagnosis of coronary artery disease (CAD) is not in question; (4) the symptoms are mild and do not interfere significantly with quality of life; and (5) medical therapy has not been optimized. In this discussion, GDMT will refer to lifestyle and pharmacological therapy for secondary prevention and for treatment of angina. For this clinical scenario, we recommend an approach using patient-centered shared decision-making (SDM) to enable clinicians and patients to discuss treatment options and decide whether to pursue a conservative or invasive strategy, rather than a routine invasive strategy with cath and revascularization for all such patients (Figure 1).Figure 1. Management decision point legend, illustrating common decisions faced by clinicians and patients with stable ischemic heart disease. CABG indicates coronary artery bypass graft; CAD, coronary artery disease; and PCI percutaneous coronary intervention.Eighty percent of percutaneous coronary intervention (PCI) is performed ad hoc,1 which means that diagnostic cath …

In Mildly Symptomatic Patients, Should an Invasive Strategy with Catheterization and Revascularization Be Routinely Undertaken?