**3. The current dilemma**

The treatment of coronary artery disease can be simplified into three major therapeutic approaches: medical therapy alone, percutaneous coronary intervention (PCI), and coronary artery bypass grafting (CABG). However, deciding on which approach is optimal for the individual patient is sometimes far from simple. This decision requires not only an in depth understanding of the evidence but also the applicability of this evidence to the individual patient considering the anatomic characteristics of the disease, the clinical context, the patient's preferences, social circumstances, and available resources [ie. local expertise and access to PCI and/or CABG]. Furthermore, because there has been evolution of all of these three approaches, interpretation of the evidence has become quite complex. Comparison of different modes of therapy (eg CABG versus medical therapy or CABG to balloon angioplasty) in the past may not be as relevant in the current clinical milieu.

#### **3.1. Advances in medical therapy**

Medical therapy has made remarkable advances from a time when patients may have been treated with nitrates alone to contemporary use of a combination of antiplatelets, lipid lowering therapy (statins), beta-blockers (BB) and Angiotensin Converting Enzyme- inhibitors (ACEI)/Angiotensin Receptor Blocker (ARB). This combined therapy addresses not only patient symptoms but also modifies the disease process such that prognosis is vastly improved [7]. The growth in our understanding the impact of lifestyle modification has also played a central role in how we manage patients with CAD [8].
