International Circulation: You will give a presentation on the rationale and methods for coronary revascularization at CIT-TCT Plenary Session. Can you give us a brief summary of the key points of your lecture?
　　Dr Kirtane: It is actually very interesting. What we have seen a trend towards in the past couple of years in treating coronary disease is that， in the past if we saw lesions in the coronary tree by angiography then many people assumed that they ought to be treated. However， people who do good clinical medicine know that not everything needs to be treated and if you select patients appropriately who do need to be treated then those patients will often benefit quite a bit but if you treat people with lesions that are not necessarily going to affect their prognosis or symptoms then you may be exposing them to a procedure without any perceived benefit either from a symptomatic standpoint or from a prognostic one.
　　Therefore， the whole focus of my lecture is why we do what we do. It is a very basic concept but it is very worthwhile to revisit it because there is an evidence base for it is an empiric base for it as well and I think that we can learn a lot from that process.
　　International Circulation:As a clinician it seems important to know that you might be called upon to justify any procedures that you perform.
　　Dr. Kirtane: There are two aspects to that issue. There are some procedures that may be truly unnecessary and we hope that those are done in a very minimal amount and many societies are rallying around this to make sure that we are doing things that are justified. Even in people who have significant coronary disease， there is a movement to attempt to prove that treatment of those lesions is going to impact their outcome. Unquestionably， revascularization of coronary artery disease can improve patients’ symptoms but there some patients who are asymptomatic and there are other patients with lesions in potentially dangerous locations in whom we feel that we can not only improve their symptoms but we may actually be able to improve their overall prognosis in terms of death and myocardial infarction. This is an area of active investigation and there is an evolution in terms of meetings and there is a lot of discussion on adjunctive technologies in order to best serve our patients.
　　International Circulation: The ESC has published a new edition of their guidelines on myocardial revascularization with updated information on myocardial revascularization in patients with stable coronary artery disease. What is your view on the efficacy of optimal medical therapy (OMT) versus coronary revascularization in patients with stable coronary artery disease?
　　Dr. Kirtane: There has been a focus to try to address this in a guidelines-based way but one of the issues is that even when there are randomized trials in this area there is a large segment of the population that is either ineligible for participation in the trial and so therefore in clinical practice there is a shortage of randomized data in stable coronary artery disease， particularly with the current armamentarium of medical therapy that we have. The other issue that comes up in these discussions is that all trials up to this point have done diagnostic angiography as a means of ruling out severe disease. Therefore， there is a controversy in the sense that if you are already looking at the anatomy and determining which patients need to be treated outside of randomization then perhaps you are only randomizing people who are at low risk and therefore you may not find a benefit from revascularization in the population that was actually randomized. As a result， there is a movement afoot to address some of those issues through new trials that are currently being designed or proposed.
　　International Circulation: Does fractional flow reserve (FFR) play a major role in evaluating the severity of the lesion and making the decision between OMT and revascularization?
　　Dr. Kirtane: FFR， like any test， needs to be interpreted within the context of the patient. Patients come to you with symptoms because they are sick and any diagnostic test needs to incorporate what the pretest probability is for significance. I feel the data on FFR has shown that it can help you determine which lesions may be significant hemodynamically and which ones may not be and in some ways it can do this better than angiography can. However， I think FFR alone does not tell the whole picture. Ultimately， when you are a clinician， the patient tells you the story that they walk in with and if someone comes in with severe symptoms that you think is coronary disease and the FFR is borderline then certain times you should not let the FFR trump your clinical judgment.