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Background The ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial failed to show a reduction in hard clinical end points with an early invasive strategy in stable ischemic heart disease (SIHD). However, the influence of left main disease and high‐risk coronary anatomy was left unaddressed. In a large angiographic disease‐based registry, we examined the modulating effect of revascularization on long‐term outcomes in anatomically high‐risk SIHD. Methods and Results 9016 patients with SIHD with high‐risk coronary anatomy (3 vessel disease with ≥70% stenosis in all 3 epicardial vessels or left main disease ≥50% stenosis [isolated or in combination with other disease]) were selected for study from April 1, 2002 to March 31, 2016. The primary composite of all‐cause death or myocardial infarction (MI) was compared between revascularization versus conservative management. A total of 5487 (61.0%) patients received revascularization with either coronary artery bypass graft surgery (n=3312) or percutaneous coronary intervention (n=2175), while 3529 (39.0%) patients were managed conservatively. Selection for coronary revascularization was associated with improved all‐cause death/MI as well as longer survival compared with selection for conservative management (Inverse Probability Weighted hazard ratio [IPW‐HR] 0.62; 95% CI 0.58 to 0.66;P &lt;0.001; IPW‐HR 0.57; 95% CI 0.53–0.61;P &lt;0.001, respectively). Similar risk reduction was noted with percutaneous coronary intervention (IPW‐HR 0.64, 95% CI 0.59–0.70,P &lt;0.001) and coronary artery bypass graft surgery (IPW‐HR 0.61; 95% CI 0.57–0.66;P &lt;0.001).Conclusions Revascularization in patients with SIHD with high‐risk coronary anatomy was associated with improved long‐term outcome compared with conservative therapy. As such, coronary anatomical profile should be considered when contemplating treatment for SIHD.

Long‐Term Clinical Outcomes Following Revascularization in High‐Risk Coronary Anatomy Patients With Stable Ischemic Heart Disease