Asymptomatic Patients With Suspected Coronary Artery Disease: What Are Clinicians Afraid Of?

Introduction

In contemporary practice, myocardial revascularization, particularly Percutaneous Coronary Intervention (PCI), is frequently performed in asymptomatic individuals with suspected Coronary Artery Disease (CAD). This occurs despite robust evidence from Randomized Clinical Trials (RCTs) over the past two decades demonstrating that, in patients with Chronic Coronary Syndromes (CCS), neither PCI nor Coronary Artery Bypass Grafting (CABG) reduces mortality when compared with Guideline-directed Medical Therapy (GDMT). In selected populations, revascularization confers symptomatic relief, particularly among patients with frequent angina, but without prognostic advantage.

The persistence of invasive strategies in asymptomatic patients appears to be driven largely by two cognitive biases: the “oculostenotic reflex”, the impulse to correct angiographically visible stenoses, and the “oculoischemic reflex”, the perceived need to revascularize documented ischemia irrespective of symptoms. Both are rooted in the fear that untreated coronary obstructions inevitably herald sudden cardiac death or Acute Myocardial Infarction (AMI).^,

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