A very large body of evidence--predominantly retrospective--suggests that revascularization is superior to optimal medical therapy in patients with a significant amount of 'hibernating' myocardium. Contemporary cardiological practice has embraced this standard of practice, as many centres worldwide place great emphasis upon the results of viability testing by non-invasive imaging techniques in determining the need for coronary revascularization. This practice has been challenged by the recent results of the Surgical Treatment for Ischaemic Heart Failure (STICH) trial, which suggested both lack of mortality benefit from revascularization and also from viability testing. In this review article, we have summarized the pathophysiology of hibernating myocardium, briefly discussed each of the non-invasive imaging modalities used in contemporary practice for detecting myocardial hibernation before critically appraising the prospective studies in this field, most importantly the main STICH trial and viability sub-study. STICH was clearly a complex trial but has not ended the question over the benefit of revascularization in ischaemic heart failure. Finally, we have suggested a possible methodology for an 'ideal trial' designed to evaluate the role of revascularization in such patients and also explored how viability testing should be used in clinical practice in the post-STICH era.

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P atients presenting to the emergency department (ED) with chest pain represent a significant healthcare burden; the estimated annual cost to the US economy is $10 to $12 billion.1 A large proportion of ED admissions are patients with suspected acute coronary syndrome (ACS) but with a nondiagnostic ECG and a normal 12-hour troponin, although fewer than half are subsequently diagnosed with ACS.2 A retrospective study found that the mean cost per patient was ≈$3200, with 73% of cost attributable to admission time. Clinical Perspective on p 209Stress echocardiography (SE) is a safe, rapid, and reliable investigation that does not involve exposure to ionizing radiation, can be performed at the bedside, and can risk stratify such patients. 4 Our group previously reported the results of a prospective, randomized study that showed that SE was superior to exercise ECG for risk stratification and cost to diagnosis of coronary artery disease (CAD) and that a larger number of patients were safely discharged compared with exercise ECG. However, no studies to date have evaluated the clinical impact of incorporating SE, performed early for the assessment of both short-and long-term prediction of hard events (all-cause mortality and acute myocardial infarction [AMI]), into a real-world chest pain unit (CPU). Accordingly, we assessed the feasibility, safety, impact on patient triaging and discharge times, and, most importantly, the accuracy of SE in risk stratification for prediction of hard events in consecutive patients who underwent SE in our CPU.Background-Clinical assessment often cannot reliably or rapidly risk stratify patients hospitalized with suspected acute coronary syndrome. The real-world clinical value of stress echocardiography (SE) in these patients is unknown. Thus, we undertook this study to assess the feasibility, safety, ability for early triaging, and prediction of hard events of SE incorporated into a chest pain unit for patients admitted with acute chest pain, nondiagnostic ECG, and negative 12-hour troponin. Methods and Results-Accordingly, 839 consecutive patients who underwent clinical, ECG, and SE assessments within 24 hours of admission were assessed for feasibility, safety, impact on triaging and discharge, and 30-day readmission rate and were followed up for hard events (all-cause mortality and acute myocardial infarction). Of the 839 patients, 811 (96.7%) had diagnostic SE results. Median time to SE and median length of stay for normal SE patients (77%) were both 1 day. The 30-day readmission rate was 0.5%. During long-term follow-up of 27±11 months, 39 hard events (30 deaths and 9 acute myocardial infarctions) occurred. Kaplan-Meier estimates of hard events were 0.5% versus 6.6% in the normal versus abnormal SE groups, respectively, in the first year of follow-up (15 events in the first year). Among all prognostic variables, only abnormal SE (hazard ratio, 4.08; 95% confidence interval, 2.15-7.72; P<0.001) and advancing age (hazard ratio, 1.78; 95% confidence interval, 1.39-2.37; P<0.001) predi...