perfect test … to give you the perfect answer ,” said Dr . Mehran . She added , however , that we do have solid evidence that noninvasive functional testing does have an important impact on the outcomes of patients with stable coronary disease , in that if you diagnose myocardial ischemia on such tests , this is correlated with a worse outcome .

So , why would we want to give up on noninvasive testing ? Presenting his side , Dr . Windecker showed that there is substantial heterogeneity in the phenotype of stable CAD , with some being at much higher risk than others . Also , data , albeit mainly registry data , indicate that in the absence of stress testing , or in patients with negative stress tests , up to 40 % were subsequently found to have obstructive coronary lesions , which he suggested would indicate that stress testing is of limited use .

Noninvasive testing , he noted , may offer less procedural risk , but it is associated with increased risk of adverse events occurring between the time of presentation and treatment .

Dr . Windecker also pointed out that coronary angiography is not only the gold standard for the diagnosis of obstructive CAD , but that it is a much lower-risk procedure than it once was ( think , radial access ) and that it allows for the immediate treatment of obstructive disease and ad hoc functional assessment by fractional flow reserve , when needed . Noninvasive testing , he noted , may offer less procedural risk , but it is associated with increased risk of adverse events occurring between the time of presentation and treatment .

He also noted “ there is no single noninvasive test that performs adequately in all clinical settings , even in expert hands .” It is thought that anatomical testing is better to exclude CAD , but in terms of prognostic impact , the PROMISE study showed no difference in clinical outcomes between anatomical and functional testing . 13

He concluded : “ I would submit to you that you should consider coronary angiography as a noninvasive test equivalent in order to avoid inappropriate underuse .”

Dr . Senior ’ s first words of rebuttal were elegant : “ When a patient comes with chest pain , what we need to exclude is myocardial ischemia . And where is the ischemia ? It ’ s in the myocardium . So , look at the myocardium . You don ’ t have to look anywhere else , because that ’ s where the answer is . Not in the arteries .”

Dr . Senior went on to note that we have good outcomes data showing that a negative stress test is associated with a favorable prognosis , even in the absence of angiography , and that those with positive signs of ischemia on stress echocardiography need to be treated with intensive risk factor management and careful follow-up regardless of whether there is obstructive CAD or not .

So why , Dr . Senior continued , expose the patient to the risks of angiography and the possibility that they may have their hearts revascularized unnecessarily just because a lesion was found on angiography ?

If there is no sign of ischemia on noninvasive testing , and no atherosclerosis on hybrid carotid ultrasound assessment ( which he recommended ), then “ you don ’ t need any other major test to make a decision about this patient ,” he concluded . Citing data from a paper he authored , Dr . Senior said that in intermediate pre-test probability patients , the preferred test is stress echocardiography .

While Dr . Windecker took criticism for his proangiography data coming mostly from registries , Dr . Senior took flak over the ongoing issue that stress testing performed in “ regular ” hands can confer very different outcomes to stress testing done by the “ experts .”

All agreed that , at the end of the day ( or the fight …), decisions must be tailored to the individual patients and take into account the expertise and culture of the clinical center , recognizing that some centers are better at noninvasive testing , while others excel in the catheterization laboratory . That said , the gathered crowd awarded the crown to Dr . Senior , showing a clear reluctance to abandon noninvasive testing .

Stay tuned next year to see if ESC brings a bit of WWE into the proceedings . ■

References 1 . Mancia G , et al . J Hypertens . 2013 ; 31 ( 7 ): 1281-357 .

2 . James PA , et al . JAMA 2014 ; 311:507-20 .

3 . Rosendorff C , et al . J Am Coll Cardiol 2015 ; 65 ( 18 ): 1998- 2038 .

4 . Harris KC , et al . Can J Cardiol . 2016 ; 32 ( 5 ): 589-97 .

5 . The SPRINT Research Group . N Engl J Med 2015 ; 373 ( 22 ): 2103-16 .

6 . Filipovsky J , et al . Blood Press 2016 ; 25:228-34 .

7 . Nishimura RA , et al . J Am Coll Cardiol 2014 ; 63 ( 22 ): 2438-88 .

8 . Vahanian A , et al . Eur Heart J 2012 ; 33 ( 19 ): 2451-96 .

9 . Masri A , et al . Heart 2016 Aug 3 . doi : 10.1136 / heartjnl-2016-309630 . [ Epub ahead of print ]

10 . Makkar RR , et al . N Engl J Med 2015 ; 373 ( 21 ): 2015-24 . 11 . Latib A , et al . Circ Cardiovasc Interv 2015 ; 8 : pii : e001779 .

12 . Abdul-Jawad Altisent O , et al . JACC Cardiovasc Interv 2016 ; 9 ( 16 ): 1706-17 .

13 . Douglas PS , et al . N Engl J Med 2015 ; 372:1291-300 .

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