Coronary artery disease: to cath or not to cath? When and how best to cath: those are the remaining questions.

Coronary artery disease is the leading cause of death worldwide and it often clinically manifests as stable angina. The optimal diagnostic and therapeutic strategy of patients with stable angina may be controversial. Coronary revascularization with percutaneous coronary intervention (PCI) is associated with a reduction in cardiovascular events in patients with acute coronary syndrome, whereas recent trials have failed to demonstrate the superiority of myocardial revascularization over optimal medical therapy in stable angina. The treatment of a patient with stable angina is still challenging, as the definition of "stable" and "unstable" is not so clear. Moreover, the benefit of PCI in terms of quality of life is evident, and independent from its neutral effect on survival. To date, the best timing of coronary angiography and the role of further investigations on myocardial ischemia still need to be defined. On the other hand, in spite of the clear benefit on clinical outcome of an early invasive treatment of patients with acute coronary syndrome, elderly are often undertreated, whereas the overtreatment with PCI of stable patients undergoing non cardiac surgery might even increase ischemic events due to the premature discontinuation of the antiplatelet therapy, without reducing the perioperative risk.