Investigation, risk stratification and treatment of the patient with chronic coronary ischemia has the goals of relieving symptoms and of improving prognosis. Patients at high risk of death and non-fatal myocardial infarction should undergo angiography, with a view to intervention by percutaneous transluminal coronary angiosplasty (PTCA) or coronary artery bypass grafting (CABG). It is difficult to ignore the surgical benefit for left main stem, three-vessel disease, with or without impaired left ventricular function, and two-vessel disease involving the proximal left anterior descending. Medical therapy is appropriate as first-line therapy in those patients not identified as being at high risk by non-invasive methods or coronary angiography. If the medical therapy fails, both angiosplasty and bypass grafting can give relief of symptoms for the same low morality rates. When compared with surgery, PTCA does not reduce or increase morality; revascularization is less incomplete, re-intervention and additional anti-anginal therapy more frequently necessary. There is no evidence that coronary angioplasty in the context of stable angina improves survival, in patients with modest single-vessel, or perhaps even double-vessel, disease in the presence of no, or minimal, symptoms. On the other hand, angioplasty has been shown to give better symptomatic relief than medical treatment. Finally, there is not exclusive treatment and medical therapy may frequently provide additional benefit when prescribed for patients after PTCA or CABG.58SPEC. ISS.161171Selwyn, A.R., Yeung, A., Ryan, T.J., Pathophysiology of ischaemia in patients with coronary artery disease (1992) Prog Cardiovasc Dis, 35, pp. 27-39Cohn, P.F., Silent myocardial ischemia: Classification, prevalence, and prognosis (1965) Ann J Med, 79, p. 2Holmes Jr., D.R., Davis, K.B., Mock, M.B., The effect of medical and surgical treatment on subsequent sudden cardiac death in patients with coronary artery disease (1986) Circulation, 73, p. 1254. , A report from the Coronary Artery Surgery StudyBonow Ro, G.M., Chronic heart failure in the United States: A manifestation of coronary artery disease (1998) Circulation, 97, p. 282Jackson, G., Stable angina: Drugs, angioplasty or surgery? (1997) Eur Heart J, 18 (SUPPL. B), pp. B2-B10Cleland, J.G.F., Walker, A., Is medical treatment for angina the most cost-effective option? (1997) Eur Heart J, 18 (SUPPL. B), pp. B35-B42Recommendations of the Task Force of the European Society of Cardiology (1997) Eur Heart J, 18, pp. 394-413Smith, W., Kenicer, M., Tunstall-Pedoe, H., Prevalence of coronary heart disease in Scotland: Scottish heart study (1990) Br Heart J, 64, pp. 295-298Gandhi, M.M., Lampe, F., Wood, D.A., Incidence of stable angina pectoris (1992) Eur Heart J, 13, pp. 181-189De Bono, D., Investigation and management of stable angina: Revised guidelines 1998 (1999) Heart, 81, pp. 546-555Kannel, W.B., Feinleib, M., Natural history of angina pectoris in the Framingham study: Prognosis and survival (1972) Am J Cardiol, 29, pp. 154-163Bruneli, C., Cristofani, R., L'Abbate, A., Long term survival in medically treated patients with ischemic heart disease and prognostic importance of clinical and electrocardiographic data (1989) Eur Heart J, 10, pp. 292-303Yusuf, S., Peduzzi, P., Fisher, L.D., Effect of coronary artery bypass graft surgery on survival: Overview of 10-year results from randomized trials by the Coronary Artery Bypass Graft Surgery Trialists collaboration (1994) Lancet, 344, pp. 563-570Deedwania, P., Carabajal, E., Silent ischemia during daily life as an independent predictor of mortality in stable angina (1990) Circulation, 81, pp. 748-756Von Arnim, T., Prognostic significance of transient ischemic episodes: Response to treatment shows improved prognosis (1996) J Am Coll Cardiol, 28, pp. 20-24. , for the TIBBS investigatorsMiranda, C.R., Lehman, K.G., Froelicher, V.F., Correlation between resting segment depression, exercise testing, coronary angiography and long term prognosis (1991) Am Heart J, 122, pp. 1617-1628Bruce, R.A., Hossack, K.F., DeRouen, A., Enhanced risk assessment for primary coronary heart disease events by maximal exercise testing. 10 years' experience of Seattle heart watch (1983) J Am Coll Cardiol, 2, pp. 565-572Dargie, H.J., Guidelines for cardiac exercise testing (1993) Eur Heart J, 14, pp. 969-988Guidelines for cardiac exercise testing (1993) Eur Heart J, 14, pp. 969-988Froelicher, V., Thompson, A.G., Wolthius, A., Angiographic abnormalities in asymptomatic aircrewmen with electrocardiographic abnormalities (1974) Am J Cardiol, 39, pp. 32-40Wolf, E., Tzivoni, D., Stern, S., Comparison of exercise tests and 24-hour ambulatory electrocardiographic monitoring in detection of ST-T changes (1974) Br Heart J, 36, pp. 90-95De Bono, D.R., Complications of diagnostic cardiac catheterization: Results from 34,041 patients in the United Kingdon confidential enquiry into cardiac catheter complications (1993) Br Heart J, 73, pp. 297-300Collaborative overview of randomized trials of antiplatelet therapy-I. Prevention of death, myocardial infarction and stroke by prolonged antiplatelet therapy in various categories of patient (1994) BMJ, 308, pp. 81-106Kannel, W.B., Mcgee, D.L., Diabetes and cardiovascular disease: The Framingham study (1979) Jama, 241, pp. 2035-2038Califf, R.M., Mark, D.B., Harrell, F.E., Importance of clinical measures of ischemia in the prognosis of patients with documented coronary artery disease (1988) J Am Coll Cardiol, 11, pp. 20-26Effect of bypass surgery on survival in patients in low and high risk subgroups delineated by the use of simple clinical variables (1981) Circulation, 63, pp. 1329-1338Brown, K.A., Prognostic value of thallium-201 myocardial perfusion imaging: A diagnostic tool comes of age (1991) Circulation, 83, pp. 363-381Brown, K.A., Boucher, C.A., Okada, R.D., Prognostic value of exercise thallium-201 imaging in clinicians presenting for evaluations of chest pain (1983) J Am Coll Cardiol, 1, pp. 994-1001Smith, S.C., Blair, S.N., Criqui, M.H., Preventing heart attack and death in patients with coronary disease (1995) Circulation, 92, pp. 2-4Fletcher, G.F., Froelicher, V.F., Hartley, L.H., A statement for health professionals from the American Heart Association (1990) Circulation, 82, pp. 2286-2319Jousilahti, P., Tuomilehto, J., Vartlainen, E., Body weight, cardiovascular risk factors, and coronary mortality (1996) Circulation, 93, pp. 1372-1373Kannel, W.B., Dawber, T.R., Kogan, Factor of risk in the development of coronary heart disease: Six years follow-up experience (1961) Ann Int Med, 55, pp. 33-50. , The Framinghan StudyFletcher, A.E., Bulpitt, C.J., How far should blood pressure be lowered? (1992) N Engl J Med, 326, pp. 251-254Berson, G.S., Wattingney, W., Tracy, R.E., Atherosclerosis of the aorta and coronary aneries and cardiovascular risk factors in persons aged 6 to 30 years and studied at necropsy (the Bogalusa Heart Study) (1992) Am J Cardiol, 70, pp. 851-853Malenka, D.J., Baron, J.A., Cholesterol and coronary heart disease: The importance of patient specific attributable risk (1988) Arch Int Med, 148, pp. 2247-2252Donahue, R.P., Abbott, R.D., Bloom, E., Central obesity e coronary heart disease in men (1987) Lancet, 1, pp. 821-824Lewin, B., Cay, E., Todd, I., The angina management programme: A rehabilitation treatment (1995) Brit J Cardiol, 2, pp. 221-225Effects of estrogen or estrogen/ progestin regimens on heart disease risk factors in postmenopausal women (1995) Jama, 273, pp. 199-208Ridker, P.M., Manson, J.E., Gaziano, J.M., Low dose aspirin therapy for chronic stable angina (1991) Ann Int Med, 114, pp. 835-839Gent, M., Beaumont, D., Blanchard, J., A randomized, bunded trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE) (1996) Lancet, 348, pp. 1329-1339Cohn, P.F., Pharmacological treatment of ischaemic heart disease: Monotherapy vs combination tnerapy (1997) Eur Heart J, 18 (SUPPL. B), pp. B27-B34ISIS-4: A randomized factorial trial assessing early oral captopril, oral mononitrate, and intravenous magnesium sulphate in 58050 patients with suspected acute myocardial infarction (1995) Lancet, 345, p. 669GISSI-3: Effects of lisinopril and transdermal glyceryl trinitrate singly and together on 6-week mortality and ventricular function after acute myocardial infarction (1994) Lancet, 343, p. 1115The Beta-Blocker Pooling Project Research Group (BBPP): Subgroup findings from randomized trials in post infarction patients (1988) Eur Heart J, 9, pp. 8-16Effect of verapamil on mortality and mayor events after acute myocardial infarction (the Danish Verapamil infarction Trial II - DAVIT II) (1990) Am J Cradiol, 66, p. 779Gibson, R.S., Boden, W.E., Theroux, P., Diltiazen and reinfarction in patients with non Q-wave myocardial infarction: Results of a doubleblind, randomized, multicenter trial (1986) N Engl J Med, 315, p. 423Jackson, G., Combination therapy in angina: A review of combined haemodynamic treatment and role for combined haemodynamic and cardiac metabolic agents (2001) Int J Clin Pract, 55, pp. 256-261Cross, H.R., Trimetazidine for stable angina pectoris (2001) Expert Opin Pharmacother, 2, pp. 857-875Yusuf, S., Sleight, P., Pogue, J., Effects of an angiotensin-converting-enzime inhibitor, ramipril, on cardiovascular events in high-risk patients. the Heart Outcomes Prevention Evaluation Study Investigators (2000) N Engl J Med, 342, pp. 145-153Pfeffer, M.A., Braunwald, E., Moye, L.A., Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction. Results of the survival and ventricular enlargement trial (1992) N Engl J Med, 327, pp. 669-677. , The SAVE InvestigatorsParisi, A.F., Folland, E.D., Hartigan, P., A comparison of angioplasty with medical therapy in the treatment of single vessel coronary artery disease (1992) N Engl J Med, 326, pp. 10-16. , Veterans' Affairs ACME investigatorsCoronary angioplasty versus medical therapy: The second randomized intervention treatment of angina (RITA-2) trial (1997) Lancet, 350, pp. 461-468Guidelines and indications for coronary- Artery bypass graft surgery (1991) J Am Coll Cardiol, 17, pp. 543-589Comparison of coronary bypass surgery with angioplasty in patients with multivessel disease (1996) N Engl J Med, 335, pp. 217-225Macaya, C., Serruys, P.W., Ruygrok, P., Continued benefit of coronary stetting versus baloon angioplasty: 1 year clinical follow up of Benestent trial (1996) J Am Coll Cardiol, 27, pp. 225-261. , Benestent Study GroupSchomig, A., Neumann, F.J., Kastrati, A., A randomized comparison of antiplatelet and anticoagulant therapy after coronary artery stents (1996) N Engl J Med, 334, pp. 1084-1089