Antibiotics: achieving the balance between access and excess.

102 www.thelancet.com Vol 387 January 9, 2016 to be clinically signifi cant, and about 25% because PCI was likely to cause complications, would have a low likelihood of success, or failed. It is plausible that the eff ect of ranolazine might vary according to the reasons for incomplete revascularisation. Residual ischaemia caused by these untreated lesions is likely to be less in patients in whom medical treatment is thought to be suffi cient. It remains unclear whether ranolazine would have a larger eff ect on patients with little angina in whom anti-angina treatment might be satisfactory or in patients with failed revascularisation who are at increased risk of recurrent angina. Routine use of fractional-fl ow reserve to assess the severity of lesions pre-PCI would, furthermore, provide crucial information on the functional degree of incomplete revascularisation, and whether medical treatment is indeed thought to be the appropriate strategy for non-stented lesions. The results of RIVER-PCI might be a barrier to more widespread use of ranolazine, as the study indicates that it should not be the fi rst-line treatment for incompletely revascularised patients. However, a reduction in adverse events in this cohort of patients could theoretically narrow the gap between PCI and CABG and open the door to treating even more complex cases with PCI. Therefore, it can be expected that more forthcoming studies will test adjunctive medical treatments for patients with incomplete revascularisation. *Stuart J Head, A Pieter Kappetein Department of Cardiothoracic Surgery, Erasmus University Medical Center, 3000 CA, Rotterdam, Netherlands [email protected]