Sustained clinical symptomatic relief following percutaneous coronary interventions has been a puzzling issue for many years. During the old days of balloon angioplasty, when the definitions of procedural success were quite generous, subsequent ultrasound imaging underscored the marked inadequacies of our postprocedural geometric luminal gains. We clearly overestimated our angiographic accomplishments. Vascular recoil, negative remodeling, and smooth muscle cell migration and proliferation further compromised our limited success, resulting in further late loss. However, despite our rather primitive and suboptimal attempts to increase coronary arterial patency and noting subsequent angiographic restenosis rates approaching or surpassing 50%, a great many patients did appreciate clinical cardiac symptom relief following angioplasty.The widespread use of coronary stenting has successfully addressed many of the described limitations of balloon angioplasty. Our definition and expectations of procedural success have become much more rigorous as we strive for and achieve greater luminal dimensions following optimal stent deployment versus balloon angioplasty. The recoil and remodeling issues are solved and we are now faced with mostly a proliferative problem [1]. Clinical event-free survival continues to improve and angiographic restenosis decreases with coronary stent deployment.The complex relationship between angiographic restenosis and clinical events remains interesting and less well understood. Symptom status, stress testing, and noninvasive imaging are all notoriously unreliable in detecting the presence of postinterventional repeat arterial obstruction. In this issue, Chen et al. report on a consecutive series of stented patients who had follow-up angiography; 41% of all patients had angiographic in-stent restenosis. However, only 22% of this restenotic group had adverse clinical cardiac events supporting what we have long known, the disconnect between angiography and symptoms in post-PCI patients.Therapeutic benefit from PCI involves more than just geometric lumen enlargement. Pacivation of the vessel wall [2,3] is important in providing clinical benefit even in those patients who have lost the patency advantages of successful PCI. In-stent restenosis provides a model to observe the clinical sequelae of lumen compromise almost exclusively due to a metabolically quiet fibrocellular wallpaper.In this setting, we might expect that cardiovascular events be more related to traditional myocardial oxygen supply/demand mismatch rather than more recently appreciated issues of endothelial dysfunction or plaque inflammation or instability. While hypertension has clear association with endothelial dysfunction and plaque instability, both LV dysfunction and hypertension increase myocardial oxygen demand, perhaps partially explaining why these variables were associated with more symptoms. Initial presentation with unstable angina was greater in the symptomatic restenotic group. This clinical variable has long been associated...