This pilot study demonstrated that (1) patients with CAD and asymptomatic cardiac ischemia can be randomized to medical or revascularization strategies using a complex and demanding protocol, (2) asymptomatic cardiac ischemia can be suppressed in 40-50% of patients with clinically advanced coronary disease with relatively low to moderate doses of medication titrated over a period of 12 weeks (3). Revascularization was the most effective of the treatment strategies studied in reducing ischemia. Any type of therapy, whether it be drugs or revascularization requiring repetitive monitoring with ambulatory ECG or other methods to detect ischemia over a long period of time, will escalate the cost of quality medical care for our patients. Thus, the health care costs implications and treatment of asymptomatic ischemia are enormous. But the apparent cost advantage of treating only symptoms, that is ignoring all ischemia, could disappear if treatment of ischemia reduces the risk of adverse events. The clinical question to be addressed in the future is what is necessary to reduce the cardiac-event rates of death and myocardial infarction in this group of patients? Will more aggressive drug therapy eliminate more ischemia and will therapy directed at the elimination of all detectable ischemia improved clinical outcome better than therapy directed to control angina only? These questions can only be answered by a large clinical trial. The results of such a trial will provide the basis and rationale for safe and effective therapy for patients with coronary disease and evidence of cardiac ischemia. Whatever the answer to this important medical and scientific question is, it will have tremendous economic implications.(ABSTRACT TRUNCATED AT 250 WORDS)