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Firstly, the stress MPI results were not blinded to the treating physicians who made the decision. Cardiologists select a more invasive strategy when patients are stable clinically without serious complications, symptomatically resistant to standard medical treatment and at high risk based on stress MPI and/or coronary lesions. This is clinically acceptable and the presented findings are biologically tenable. There, however, were apparently differences in the clinical and ischemic backgrounds between the groups treated with and without revascularization, and selection bias for indication of revascularization may have overestimated the therapeutic benefits in this study. Patients with smaller ischemic burden and preserved LVEF were treated without revascularization and had better outcomes, while revascularization was selected when patients had a larger ischemic burden and reduced LVEF (Table S1). Although the espite recent advances in cardiac imaging technology, morphological assessment of coronary anatomy tends to overestimate coronary narrowing that is not necessarily related to functional myocardial ischemia and outcomes.1 Recent multicenter studies clearly show that invasive therapeutic strategy based on coronary stenosis without initial assessment of myocardial ischemia does not necessarily improve prognosis in stable coronary artery disease (CAD) patients2–5 and that functional ischemia detection using stress myocardial perfusion imaging (MPI)3,5 or fractional flow reserve has demonstrated close correlations between the severity of myocardial ischemia and cardiac events and ischemia-based benefits of invasive and medical treatments. In this issue of the Journal, Petretta et al6 demonstrate the effects of the degree of stressinduced ischemia and post-stress left ventricular ejection fraction (LVEF), both of which were assessed by stress-gated MPI, on the prognostic benefits of revascularization in 2,059 patients with suspected or known CAD during 61 months. Despite its retrospective nature, the results derived from this large, longterm follow-up study are relevant given the strengthened recognition of the prognostic implications of functional ischemia D

Ischemic Burden Size, Left Ventricular Function or Both for Better Revascularization Outcomes?