A 68-year-old obese male patient with a history of hypertension, hyperlipidemia, and type 2 diabetes mellitus was referred to you by his primary care physician for further evaluation of progressively worsening chest discomfort and dyspnea, which have been present over the past few months. Both symptoms initially were brought on after walking up 3 flights of stairs but now are elicited with minimal exertion such as walking 100 feet. His symptoms resolve with rest. He states he does not routinely exercise but is active at his job as a construction worker. He has a 1-pack-per-day smoking history; he quit a few months ago because he attributed his exertional symptoms to his tobacco use.
His home medications include low-dose aspirin, high-dose rosuvastatin, lisinopril, and a long-acting nitrate. His blood pressure is 122/78 mmHg, and heart rate is 60 bpm. His last hemoglobin A1c was 7. An electrocardiogram in your office reveals normal sinus rhythm with an old left bundle branch block. An echocardiogram reveals a left ventricular ejection fraction of 40% with anterior, anteroseptal, and inferoseptal wall hypokinesis. Consequently, he undergoes an exercise nuclear stress test that reveals a moderately large reversible perfusion defect involving the anterior, anteroseptal, and inferoseptal myocardium. Coronary angiography shows an 80% occlusion of his mid left anterior descending (LAD) artery, a 95% occlusion of the first proximal obtuse marginal artery, and a 75% occlusion of the proximal posterior descending artery (PDA) with a dominant right coronary artery.
After discussing the angiographic findings with the patient, what is the best next step?
The correct answer is: A. Recommend coronary artery bypass grafting (CABG)
The decision to pursue coronary revascularization depends on a patient's severity of angina despite maximal medical therapy, the anatomical extent of coronary artery disease (CAD) as per angiography or noninvasive imaging, amount of myocardium at risk, and associated comorbidities conferring a mortality risk. When deciding between revascularization modalities in patients with stable ischemic heart disease (SIHD), one must consider a strategy that provides both symptom relief and a survival benefit.
Per the 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease, lifestyle modifications should always be encouraged, including daily physical activity, weight management, smoking cessation, alcohol moderation, sodium reduction, and reduced intake of saturated fats, trans fatty acids, and cholesterol (Class IB recommendation).1
Given that the patient has multivessel CAD, left ventricular systolic dysfunction, and angina with minimal exertion, the patient would benefit from coronary revascularization instead of medical therapy alone. CABG has been shown to offer a mortality benefit compared with multivessel angioplasty, especially in patients over the age of 65 with diabetes.2
Multivessel PCI could be performed if this patient did not desire bypass surgery. However, because the patient has diabetes, his risk of restenosis after stent deployment is significantly increased compared with non-diabetics and therefore may require repeat revavscularization.3 Tada et al. demonstrated in his analysis of the j-Cypher registry, containing outcomes data of 10,778 consecutive patients treated with sirolimus-eluting stents, the rate of target lesion revascularization at 3 years was 19, 14, and 10% in patients with insulin-dependent diabetes, non-insulin-dependent diabetes, and non-diabetics, respectively. A composite of death, myocardial infarction (MI), and cerebrovascular accident (CVA), as well as all-cause death were significantly higher in the same categories in a similar fashion, respectively.4
Improved survival outcomes in patients with diabetes are correlated with surgical revascularization compared with PCI. At its 5-year follow-up, the SYNTAX (Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery) trial revealed that patients with diabetes who underwent CABG had fewer major adverse cardiac and cerebrovascular events (29% CABG vs. 47% PCI; p < 0.001).5 Similarly, the FREEDOM (Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease) trial revealed that the overall composite outcome of death, MI, and CVA was higher in diabetics with multivessel CAD who underwent PCI versus CABG at a 5-year follow-up (27% vs. 19%; p = 0.005).6 PCI was shown to be independently associated with a higher risk of all-cause mortality (16% vs. 11%; p = 0.049) and MI (14% vs. 6%; p < 0.001) but was associated with a decreased risk of CVA (2.4% vs. 5.2%; p = 0.03) compared with CABG.
This patient would not be a candidate for cardiac transplantation because he has the potential for coronary revascularization.
If no absolute contraindication exists, beta-blocker therapy should be started in all patients with SIHD given its effect on decreasing myocardial oxygen demand, resulting in a reduction of angina and improvement in the ischemic threshold of exercise (Class IB recommendation).1
Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2012;60:e44-e164.
Influence of diabetes on 5-year mortality and morbidity in a randomized trial comparing CABG and PTCA in patients with multivessel disease: the Bypass Angioplasty Revascularization Investigation (BARI). Circulation 1997;96:1761-9.
West NE, Ruygrok PN, Disco CM, et al. Clinical and angiographic predictors of restenosis after stent deployment in diabetic patients. Circulation 2004;109:867-73.
Tada T, Kimura T, Morimoto T, et al. Comparison of three-year clinical outcomes after sirolimus-eluting stent implantation among insulin-treated diabetic, non-insulin-treated diabetic, and non-diabetic patients from j-Cypher registry. Am J Cardiol 2011;107:1155-62.
Mohr FW, Morice MC, Kappetein AP, et al. Coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with three-vessel disease and left main coronary disease: 5-year follow-up of the randomised, clinical SYNTAX trial. Lancet 2013;381:629-38.
Farkouh ME, Domanski M, Sleeper LA, et al. Strategies for multivessel revascularization in patients with diabetes. N Engl J Med 2012;367:2375-84.