To the Editor: The editorial by Woollard and Newman1 discussing the best management of stable coronary artery disease is welcome and timely, but we believe their conclusions undervalue the benefits of optimal medical therapy.

The authors correctly point out that the early trials comparing surgery with medical treatment did not include aspirin, β-blockers or lipid-lowering drugs in the medical treatment group. Clearly, the benefits of these treatments have been so dramatic as to make these original trials irrelevant to current practice.

After reviewing trials comparing percutaneous coronary intervention (PCI) with coronary artery bypass graft (CABG) surgery and discussing their limitations, the authors conclude that:

We believe this conclusion is only appropriate for those patients in whom an adequate trial of medical therapy has failed to achieve sufficient relief of anginal symptoms.

Based on current evidence, including that from the MASS II2 (comparing medical therapy with both CABG and PCI), COURAGE3 (comparing PCI with medical therapy) and AVERT4 (comparing intensive lipid-lowering therapy using atorvastatin with PCI) trials, we conclude the following about the management of stable coronary artery disease:

• Irrespective of whether patients under-go CABG or PCI (or neither), aggressive medical therapy combined with appropriate lifestyle measures is the means by which patients are protected from major adverse cardiovascular events.

• There is no evidence that either PCI or surgical treatment is superior to the current best medical treatment in preventing death or myocardial infarction. Patients with stable angina should be informed accordingly and be reassured that their symptoms are likely to abate or resolve with optimal medical treatment over a period of time.

• Intervention should be reserved for patients in whom an adequate trial of medical treatment has failed to relieve symptoms or in whom medication is poorly tolerated, and possibly for patients in whom satisfactory anti-atherosclerosis treatment targets cannot be achieved.

Performing PCI and CABG in patients with stable angina consumes a significant portion of the Medicare budget. We believe many patients with absent or relatively minor symptoms consent to these procedures in the mistaken belief that their lives will be prolonged. Application of evidence-based guidelines would significantly reduce the number of interventions currently performed and make much needed resources available for prevention strategies and for selected patients with acute coronary syndromes in whom this expensive treatment has proven benefit.

Lastly, we strongly support the implication by Woollard and Newman that patients should “undertake consultation with other providers” regarding treatment options — including medical therapy.

In reply: We agree with Harper and colleagues that for most patients with stable coronary artery disease, prevention of death or other cardiac events is best achieved with medical treatment. Many patients and even some doctors are so impressed by the restoration of coronary blood flow achieved with angioplasty that they incorrectly assume it will provide a prognostic benefit.

However, we do not agree that intervention should be reserved for patients in whom medical treatment has failed. It is unlikely that a trial comparing current medical treatment with coronary artery bypass graft (CABG) surgery for severe left main coronary disease will ever be performed, and current evidence favours CABG at least in this group. In addition, many patients with angina prefer a mechanical intervention to long-term antianginal medications, and why should they be denied that choice?