Pathway for the management of patients based on stress echo results

The objective of an ideal stress testing modality is to effectively risk stratify patients with known or suspected coronary artery disease (CAD) for future cardiovascular events. This is crucial as treatment options and the benefits of treatment vary with the risk category of patients. Surgical literature suggests that the morbidity and mortality benefits of surgical revascularization for CAD is highest in the intermediate to high-risk subgroups, whereas there is a trend toward increased mortality in the low-risk cohort compared to medical therapy alone.1 In the recently concluded Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial of 2287 patients with stable CAD, an initial revascularization strategy using percutaneous coronary intervention (PCI) did not reduce the risk of death, myocardial infarction, or other major cardiovascular events when added to optimal medical therapy,2 thus creating an intense debate among physicians, media, and the public on the utility of PCI in patients with abnormal stress test and CAD.