Transmyocardial laser revascularization (TMR) performed as an adjunct to CABG to improve symptoms may be reasonable in patients with viable ischemic myocardium that is perfused by arteries that are not amenable to grafting.397 401 (Level of Evidence: B) Class III: HARM 1. CABG or PCI to improve symptoms should not be performed in patients who do not meet anatomic (>50% left main or >70% non left main stenosis) or physiological (eg, abnormal fractional flow reserve) criteria for revascularization. (Level of Evidence: C) 3.4. CABG Versus Contemporaneous Medical Therapy In the 1970s and 1980s, 3 RCTs established the survival benefit of CABG compared with contemporaneous (although minimal by current standards) medical therapy without revas- cularization in certain subjects with stable angina: the Veter- ans Affairs Cooperative Study,402 European Coronary Sur- gery Study,344 and CASS (Coronary Artery Surgery Study).403 Subsequently, a 1994 meta-analysis of 7 studies that randomized a total of 2649 patients to medical therapy for CABG318 showed that CABG offered a survival advan- tage over medical therapy for patients with left main or 3-vessel CAD. The studies also established that CABG is more effective than medical therapy at relieving anginal symptoms. These studies have been replicated only once during the past decade. In MASS II (Medicine, Angioplasty, or Surgery Study II), patients with multivessel CAD who were treated with CABG were less likely than those treated with medical therapy to have a subsequent MI, need addi- tional revascularization, or experience cardiac death in the 10 years after randomization.392 Surgical techniques and medical therapy have improved substantially during the intervening years. As a result, if CABG were to be compared with GDMT in RCTs today, the relative benefits for survival and angina relief observed several decades ago might no longer be observed. 