Angiography Is the Gold Standard and Objective Evidence of Myocardial Ischemia Is Mandatory If Lesion Severity Is Questionable : – Indication of PCI for Angiographically Significant Coronary Artery Stenosis Without Objective Evidence of Myocardial Ischemi

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The indications for percutaneous coronary intervention (PCI) have expanded, especially after the approval of drug-eluting stents, for both complex lesions and those with intermediate stenosis. Because recent randomized trials have demonstrated the non-inferiority of optimal medical treatment for stable angina compared with coronary revascularization, and the benefits of PCI guided by coronary pressure measurement have been shown in another trial, the appropriateness of current indications for PCI has been called into question. In the evaluation of coronary artery stenosis, inter- and intraobserver variabilities can be problematic. Therefore, the use of PCI for intermediate coronary stenosis based on angiographic evaluation alone without documentation of myocardial ischemia could be questionable. Guidelines mention that physiological assessment of myocardial ischemia is most useful in patients with intermediate coronary artery stenosis, while interobserver differences in the assessment of severe stenosis are usually small. Accordingly, routine provocation testing for myocardial ischemia before PCI may be less than ideal for real-world practice, and the indications for PCI should be multifactorial. (Circ J 2011; 75: 204-210)