Patients at highest risk, for example, are often identified and aggressively treated during the course of ACS or during initial risk assessment of chest pain. After being treated, asymptomatic patients are typically at low risk for adverse events. Moreover, patients with recognized SIHD could be more likely to receive and adhere to effective therapies than are those whose disease has not been docu- mented. Finally, patients who have been stable for long periods of time could be less prone to development of ACS than are newly ascertained patients with SIHD. Thus, evidence-based medical management, including adherence to appropriate lifestyle changes and possibly appropriate revas- cularization in patients with ACS or patients identified as high risk with worsening clinical status or persistent symp- toms despite GDMT, could explain the generally low mor- tality risk that has been found in several studies of patients with established but stable SIHD.57,58,366,1216,1217 Moreover, large trials conducted during the past decade have shown a declining mortality rate among patients with established SIHD.295,898,1163,1217,1218 Accordingly, risk could change with advances in therapy and patient management, and these advances could alter risk-prediction models. A key component in following up patients with SIHD is to systematically and reproducibly monitor their symptoms and functional status. This should be done, at a minimum, yearly and ideally at each visit. Even though the CCS classification system is the most common metric with which to quantify patients symptoms and function, as noted previously, it is limited by being from the physician s perspective rather than the patient s. Moreover, it has limitations in its reproducibil- ity and interrater reliability. 