Current guidelines from the American College of Cardiology and the American Heart Association advise against routine preoperative noninvasive testing before noncardiac surgery unless the results are likely to influence management.⁵ However, registry data from the United States show that most preoperative cardiac catheterizations are done in asymptomatic patients, with revascularization suggested in nearly a quarter of cases.⁶ Importantly, the randomized trial by McFalls and colleagues found no reduction in mortality or myocardial infarction with prophylactic revascularization before major vascular surgery.⁷

Appropriateness analyses further highlight this issue. In a nationwide U.S. registry encompassing over 1.2 million PCIs performed in stable CAD, approximately one quarter were classified as rarely appropriate.⁸ A substudy of the ISCHEMIA trial reinforced these findings, showing that anatomical complexity (number of diseased vessels, SYNTAX score, proximal left anterior descending involvement) and diabetes did not identify subgroups deriving incremental prognostic benefit from an initial invasive strategy. Rather, baseline symptom burden and antianginal therapy were the principal determinants of health-status improvement.⁹

The belief that asymptomatic ischemia predicts sudden death remains deeply ingrained in clinical culture. However, in ISCHEMIA, the annual incidence of sudden cardiac death among patients with moderate-to-severe ischemia treated conservatively was approximately 0.4%.^10,11 Furthermore, although spontaneous myocardial infarction occurred more frequently in the conservative arm, periprocedural infarctions in the invasive arm offset this difference, resulting in similar overall AMI rates at follow-up.¹⁰

Nearly four decades ago, Atilio Maseri observed that diagnostic and therapeutic decisions are often driven more by fear of death and infarction than by symptom relief. This observation remains pertinent.¹² Misinterpretation of the role of PCI in CCS — particularly conflating anatomical correction with prognostic benefit — likely underlies much of the current practice variation.¹³

A critical question emerges: how can a diagnostic test alter prognosis in asymptomatic individuals in the absence of a proven effective downstream intervention?

Noninvasive strategies — whether anatomical (coronary CT angiography) or functional (stress testing with imaging) — frequently increase rates of cardiac catheterization and revascularization without reducing hard clinical endpoints.

In the SCOT-HEART trial, CT angiography plus usual care was associated with a modest absolute reduction (1.6%) in the composite endpoint of cardiovascular death or nonfatal AMI compared with usual care alone.¹⁴ However, no reduction in all-cause mortality was observed. Furthermore, greater use of preventive therapies in the CT group raises concerns regarding treatment imbalance. The study's fragility index further suggests limited statistical robustness.¹⁵

Conversely, the PROMISE trial, which randomized over 10,000 patients to anatomical versus functional testing strategies, demonstrated no difference in major cardiovascular outcomes between approaches.¹⁶ Similarly, the FACTOR-64 trial found no reduction in death, AMI, or unstable angina hospitalization among asymptomatic diabetic patients screened with CT angiography compared with usual care.¹⁷

At the population level, the Danish DANCAVAS study, which screened more than 46,000 community-dwelling men for multiple cardiovascular conditions, including CAD, found no mortality reduction after more than five years of follow-up.¹⁸

Collectively, these data indicate that screening asymptomatic individuals for CAD does not translate into improved survival or reduced myocardial infarction rates.

While screening and revascularization have not demonstrated prognostic benefit in asymptomatic individuals, intensive risk factor modification has consistently shown a durable impact.

A substudy of the COURAGE trial revealed a striking gradient in long-term outcomes: after 14 years, mortality was 8% among patients who achieved control of all major risk factors compared with 28% among those who controlled none.¹⁹ Similarly, analyses from ISCHEMIA demonstrated that attainment of comprehensive GDMT targets — systolic blood pressure < 130 mmHg, LDL cholesterol < 70 mg/dL, smoking cessation, and antiplatelet therapy — was associated with a 16-percentage-point absolute reduction in cardiovascular death or myocardial infarction over four years (number needed to treat < 7).²⁰

These findings emphasize that prognosis in stable CAD is determined less by focal coronary stenoses and more by systemic atherosclerotic burden and its modifiable determinants.