Newer studies have challenged the widely held assumptions that revascularization consistently reduces cardiac events and prolongs survival (13 - 14). The OAT (Occluded Artery Trial) enrolled 2166 patients who had an occluded infarct-related coronary artery early after myocardial infarction and another high-risk criterion, such as proximal stenosis in a different coronary artery (13). In OAT, PCI did not confer an advantage over medical therapy for the combined end point of death, reinfarction, or New York Heart Association class IV heart failure. The COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial, the largest reported RCT in chronic coronary artery disease, enrolled 2287 patients with significant coronary artery disease and inducible ischemia; 70% had multivessel disease, and more than one third had stenoses in the proximal left anterior descending artery (14). The trial compared optimal medical therapy with and without PCI. Unlike medical therapy in earlier trials that focused on antianginal medication, all patients in the COURAGE trial received intensive, goal-directed risk factor reduction therapy that resulted in very high rates of adherence to guideline recommendations for blood pressure, lipid levels, exercise, diet, and smoking cessation. When added to such intensive medical therapy, PCI had no advantage in terms of the primary end point of death or myocardial infarction and only a modest advantage in relief of angina that decreased over time (possibly because more late PCIs were done in the group that initially received only medical therapy). These results suggest that revascularization can safely be deferred for many patients if the standards for medical therapy in the COURAGE trial are scrupulously followed.