George W Bush’s recent decision to consent—in the absence of symptoms—to the implantation of a stent by an interventional cardiologist has led to an entirely justifiable debate on how best to treat stable coronary artery disease. Though the clinical benefit of percutaneous coronary intervention (PCI) in managing acute coronary syndromes has been proved,1 2 3 4 many robust randomised studies (which included patients at low and at high risk) have not shown any prognostic value in stenting for stable angina in addition to optimal medical therapy.5
Given the complications related to the procedure, the fact that many serious events result from non-significant lesions,6 the potentially thrombotic milieu created by a metal scaffold apposed to the intima of a coronary artery after it is stretched by a balloon, and the potency of lifestyle interventions and pharmacotherapy, it is perhaps easier to understand that even stenting a 90% stenosed artery for stable angina does not prevent heart attacks or prolong life. Yet such practice continues to contribute to overspending in healthcare in the United States, whose total healthcare spending is predicted to …