How do you approach a patient at intermediate ASCVD risk who has been referred to you because of an abnormal coronary CTA (obstructive lesion ~90%) but an excellent exercise capacity on treadmill without angina and a negative MPI?  

Unless the reported lesion involves proximal LAD or LM (MPI can look normal if balanced ischemia), I would then treat medically (ISCHEMIA trial, ACC/AHA stable CAD guidelines).

This is now a patient with CAD (severe single vessel CAD) and the patient should be very clear about this diagnosis; the absence of Sx and excellent functional capacity, while comforting, does little to minimize the need for maximal medical Rx with at least ASA and statin Rx. An interval decline in ...