Madsen et al 1 compared an invasive strategy of coronary arteriography and revascularization with a conservative strategy in patients with inducible myocardial ischemia after thrombolysis for a first myocardial infarction. Just over 500 patients aged Յ69 years and able to perform an exercise test were randomized to each strategy. The invasive-strategy patients underwent 266 angioplasty procedures and 147 bypass operations. There was no significant difference in mortality between the 2 groups at a median of 2.4 years. Rates of reinfarction and of readmission for unstable angina were 5.6% and 17.9%, respectively, for the invasive strategy and 10.5% and 29.5%, respectively, for the conservative strategy. From this, Madsen et al conclude that all subjects with inducible ischemia after a thrombolyzed first myocardial infarction should be revascularized and then extend this sweeping recommendation, without any analysis of costs, days hospitalized, and quality of life, to all postinfarction patients with inducible ischemia.It is unclear why in this study the invasive strategy's absolute reduction of only 4.9% in the occurrence of myocardial infarction and of 11.6% in the number of admissions for unstable angina over 2.4 years, statistical significance notwithstanding, with no demonstrated reduction in mortality, constitutes sufficient clinical justification for sending all patients with inducible ischemia for coronary revascularization. Should patients with inducible ischemia who are symptomatic and limited to Յ5 metabolic equivalents (METs) be managed in the same way as asymptomatic patients with inducible ischemia performing Ն7 METs or Ͼ10 METs? Should all patients be similarly treated regardless of the degree of ST-segment depression or regardless of the threshold at which ischemia appears? Why should their risk be assumed to be the same? The study by Madsen et al provides no information on the occurrence of events in these clinically pertinent subsets of patients with inducible ischemia. Furthermore, it is questionable to randomize patients with inducible ischemia and a poor exercise performance (Ͻ5 METs), because several studies in both stable angina and after myocardial infarction have shown that such patients have a poor prognosis and therefore should undergo an "invasive strategy." [2][3][4][5][6][7] The randomization of such patients loads the question being asked in favor of this strategy. It risks sending a wrong message (as does the accompanying editorial 8 ) and does not advance our understanding of how to manage the other subsets of patients with inducible ischemia, which is the clinically relevant question.It is also unclear why revascularization in these subjects with inducible ischemia should have reduced the occurrence of myocardial infarction, because several studies, such as GISSI-2, 9 have shown the inability of a positive postinfarction exercise test to predict reinfarction. In addition, less than half the conservatively treated patients were taking -blocking agents after an infarction with induc...