A 78-year-old man with hypertension, hyperlipidemia, and history of smoking was referred to you by his primary care physician for further evaluation of substernal chest discomfort and dyspnea on exertion that has gradually developed over the last several months with no symptoms at rest. An electrocardiogram in the office revealed sinus rhythm with a left bundle branch block, which is chronic, and a corrected QT interval of 530 ms. On echocardiogram, left ventricular ejection fraction (LVEF) was 45% with anterior and anteroseptal wall hypokinesis. You ordered an exercise myocardial perfusion study, which showed a stress-induced perfusion defect involving 10% of the anterior and anteroseptal myocardium. He was then referred for coronary angiography, which revealed a chronic total occlusion (CTO) of his mid-left anterior descending (LAD) artery with grade 3 collaterals from a dominant right coronary artery. You decided to add a long-acting nitrate in addition to his home dose of beta-blocker and reassess his symptoms. He returned to your office 2 months later, now on highest tolerated doses of beta-blocker and nitrate limited by blood pressure with persistent angina.
What is the most appropriate next step?
Show Answer
The correct answer is: C. Discuss risks and benefits of percutaneous coronary intervention (PCI) of CTO of the LAD artery.
This patient had an intermediate-risk stress test with a moderately reduced LVEF and had tried two antianginal drugs without significant symptomatic benefit. According to the ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2017 Appropriate Use Criteria for Coronary Revascularization in Patients With Stable Ischemic Heart Disease,1 it is appropriate to consider PCI with an aim to revascularize in patients with stable ischemic heart disease who are experiencing ischemic symptoms despite being on ≥2 antianginal drugs. With a reduced LVEF and wall motion abnormalities, which can be attributed to his coronary anatomy with a reasonable amount of certainty, PCI is appropriate because there is some evidence that it may lead to improvement in LVEF in patients with CTO of LAD compared to optimal medical therapy.2,3
It is of paramount importance that the patient be involved in a shared decision-making process and be made fully aware of the goals of intervention, the potential risks involved, and the odds of technical failure to revascularize. Technical success can be predicted by validated models such as the J-CTO4 and PROGRESS CTO5 scoring systems, which might help when counseling the patient. The use of the hybrid algorithm6 aids in greater success and a more standardized approach across centers.
CABG surgery may be appropriate in patients with single vessel disease without proximal LAD or left main involvement but should not be routinely recommended without first discussing the option of PCI, which is more appropriate in this case.1 There is concern for ventricular arrhythmias in patients with a prolonged QT interval and ranolazine. Enhanced external counterpulsation and transmyocardial revascularization surgery for angina lack robust evidence to justify their routine use; PCI is more appropriate in this case.
References
Patel MR, Calhoon JH, Dehmer GJ, et al. ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2017 Appropriate Use Criteria for Coronary Revascularization in Patients With Stable Ischemic Heart Disease: A Report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society of Thoracic Surgeons. J Am Coll Cardiol 2017;69:2212-41.
Henriques JP, Hoebers LP, Råmunddal T, et al. Percutaneous Intervention for Concurrent Chronic Total Occlusions in Patients With STEMI: The EXPLORE Trial. J Am Coll Cardiol 2016;68:1622-32.
Galassi AR, Boukhris M, Toma A, et al. Percutaneous Coronary Intervention of Chronic Total Occlusions in Patients With Low Left Ventricular Ejection Fraction. JACC Cardiovasc Interv 2017;10:2158-70.
Morino Y, Abe M, Morimoto T, et al. Predicting successful guidewire crossing through chronic total occlusion of native coronary lesions within 30 minutes: the J-CTO (Multicenter CTO Registry in Japan) score as a difficulty grading and time assessment tool. JACC Cardiovasc Interv 2011;4:213-21.
Christopoulos G, Kandzari DE, Yeh RW, et al. Development and Validation of a Novel Scoring System for Predicting Technical Success of Chronic Total Occlusion Percutaneous Coronary Interventions: The PROGRESS CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention) Score. JACC Cardiovasc Interv 2016;9:1-9.
Brilakis ES, Grantham JA, Rinfret S, et al. A percutaneous treatment algorithm for crossing coronary chronic total occlusions. JACC Cardiovasc Interv 2012;5:367-79.
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