It might also be the case that a patient expresses a preference for a treatment approach (eg, PCI) when the practitioner believes another approach (eg, GDMT) would be preferable. Although practitioners always should engage patients in a detailed discussion about their individual goals and values in order to tailor therapy, this is particularly important when therapeutic goals or the patient s or provid- er s preferences are not aligned. It is essential that these discussions be conducted in a location and atmosphere that permits adequate time for discussion and contemplation. Initiating a discussion about the relative merits of medical therapy versus revascularization while a patient is in the midst of procedure, for example, is not usually consistent with these principles. Reducing the risk of mortality should be pursued as intensively as is sensible for all patients with SIHD. It has been estimated that nearly half of the dramatic decline in cardiovascular mortality observed during the past 40 years is attributable to interventions directed at modifying risk fac- tors. Of this change, 47% can be attributed to treatments, including risk factor reduction after AMI, other guideline- based treatments for UA and heart failure, and revasculariza- tion for chronic angina.391 An additional 44% reduction in age-adjusted death is attributed to population-based changes in risk factors.391 Unfortunately, these changes have been offset somewhat by increases in BMI and type 2 diabetes mellitus, which result in an increased number of deaths.391 The 2011 secondary prevention and risk reduction therapy statement8 summarizes the key interventions known to im- prove survival and prevent subsequent cardiac events. 