A 66-year-old man with stable angina at low exertion level was investigated with coronary angiography that showed an isolated significant lesion (70%) of the ostium and mid-portion of the left main coronary artery in the presence of a normal left ventricular function.
What is the correct statement regarding the recommended approach?
Heart team discussion between the interventional cardiologist and the cardiac surgeon to select the best treatment option is the recommended approach. The 2011 AHA/ACC guidelines for PCI recommend the heart team approach (class I, evidence C) for the revascularization of patients with unprotected left main trunk disease. Several trials used protocols that involve a multidisciplinary approach. The heart team is composed of an interventional cardiologist and a cardiac surgeon and aims at (1) reviewing patients’ medical history, (2) determining the approach of revascularization (PCI versus CABG), and (3) discussing with the patient the options of revascularization. The guidelines endorse a heart team approach in patients with unprotected left main CAD and/or complex CAD in whom the optional strategy is not straightforward. Because the STS score and the SYNTAX score predict clinical outcomes, their use is often useful in making revascularization decisions.
A 58-year-old man with coronary artery disease (CAD) and severe chronic obstructive pulmonary disease (COPD) with forced expiratory volume in the first second of expiration (FEV1 )/forced vital capacity <0.74 with FEV1 <40% predicted had stenting of the mid-left anterior descending artery (LAD) 10 months prior to admission with a 3.0 mm × 24 mm bare metal stent (BMS). He presents now with recurrent angina despite intensified medical treatment, and coronary angiography reveals a severe and diffuse in-stent restenosis (ISR).
A reasonable next therapeutic option would be:
Drug-eluting stent (DES) implantation (stent-in-stent). In the randomized trial TAXUS V ISR (treatment of De Novo Coronary Disease Using a Single Paclitaxel-Eluting Stent trial), the slow-release, polymer-based, paclitaxeleluting stent was found to be not only noninferior to β-source vascular brachytherapy but also superior in terms of reducing clinical and angiographic restenosis at 9 months after treatment of bare-metal ISR lesions. Because of both greater acute gain and less late loss, luminal dimensions were significantly larger with paclitaxel-eluting stents compared with brachytherapy in the injury zone, at the distal edge, and over the entire analysis segment. Proximal edge luminal dimensions were also numerically larger with the paclitaxel-eluting stent. Similarly, the Sirolimus-Eluting Stent with Vascular Brachytherapy for the Treatment of In-Stent Restenosis (SISR) trial demonstrated a marked reduction in target vessel failure with the sirolimus-eluting stent, driven predominantly by a reduction in the rate of target vessel revascularization. Based on available data and the severity of the patient’s COPD, DES implantation is the best option for this patient with BMS restenosis. Brachytherapy is no longer available except in a few research centers.
A 66-year-old man had in the last few months sporadic episodes of chest pain on exertion. His cardiovascular (CV) risk factors included diabetes, hypertension, and hypercholesterolemia. He had no other comorbidity. Coronary angiography revealed a lesion of 60% of the RCA in addition to multiple nonsignificant plaques affecting the three coronary arteries. The fractional flow reserve (FFR) of the RCA (0.0.85) and LVEF were normal.
What is the recommended treatment for this patient?
Guideline-directed medical therapy is the first recommended approach. In the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial, 2,287 patients with stable CAD were randomized to undergo PCI and medical therapy or to medical therapy alone. The primary outcome was death from any cause and nonfatal MI during a follow-up of 2.5 to 7.0 years. The cumulative event rates were 19.0% in the PCI group and 18.5% in the medical therapy group (P = 0.62). As an initial management strategy, PCI did not reduce the risk of death, MI, or other MACE in the COURAGE trial. About 314 patients were enrolled in the nuclear substudy of the COURAGE study to perform serial stress imaging. The addition of PCI to medical therapy improved ischemia reduction in patients with significant ischemia at baseline. A recent metaanalysis of 10 randomized controlled trials (6,752 patients) comparing PCI with medical therapy in stable CAD did not detect significant differences in PCI versus CABG; the relative risk (RR) for all-cause mortality was 0.97 (95% CI: 0.84 to 1.12), CV mortality RR 0.91 (95% CI: 0.70 to 1.12), MI RR 1.09 (95% CI: 0.92 to 1.29), or angina relief RR 1.10 (95% CI: 0.97 to 1.26). 18 According to the AHA/ACC guidelines CABG or PCI should not be performed to improve symptoms or survival in patients with CAD with one or more coronary stenoses who do not meet anatomic (≥70% non-left main stenosis diameter), physiologic (FFR >0.80, no or mild ischemia on noninvasive testing) criteria for revascularization and involve only LCX or RCA, or subtend only a small area of viable myocardium. 5 The multiple meta-analyses comparing PCI versus medical therapy in patients with SIHD showed that PCI reduced the incidence of angina, but has not been demonstrated to improve survival or lower the long-term risk of MI in stable patients. Our patient does not have criteria for coronary revascularization, and the first-line therapy should be an aggressive medical therapy.
A 58-year-old male smoker treated for hypertension complained about chest pain on exertion in the preceding 4 weeks. To investigate the clinical symptoms, you performed a stress perfusion cardiac magnetic resonance showing hypoperfusion during IV administration of adenosine.
Which area of the myocardium is more vulnerable to hypoperfusion?
Subendocardium. The subendocardium is most susceptible to ischemic damage. Although the mechanisms of subendocardial ischemia remain to be fully defined, they are clearly associated with the transmural distribution of intramyocardial systolic pressures. Even though almost all the myocardium is perfused in diastole, a reduction of diastolic perfusion pressure or duration will result in subendocardial ischemia. The abnormal subendocardial perfusion in patients with cardiac syndrome X (typical angina, abnormal exercise test results, and normal coronary arteries) has been described with CV MR imaging during the IV administration of adenosine.
A 73-year-old man presents to the emergency room with severe mid-sternal chest discomfort. He appears anxious and in distress. His heart rate is 66 bpm, blood pressure is 92/68 mmHg, and respiratory rate is 14. There is marked jugular venous distention. Cardiac auscultation is unremarkable and the lungs are clear. ECG reveals 2-mm ST-segment elevation in leads II, III, and aVF. The most likely diagnosis is:
Inferior wall myocardial infarction (MI) with right ventricular infarction. The association of inferior wall MI on ECG and elevated jugular venous pressure with clear lungs is suggestive of additional right ventricular infarction. Tall c–v waves of tricuspid regurgitation may be evident in patients with necrosis or ischemia of the right ventricular papillary muscles.
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