Revascularisation of LM: How to Decide and What to Expect

A 51-year-old Caucasian man was transferred to the emergency department from a nearby non-interventional hospital with a diagnosis of non-ST-segment elevation myocardial infarction. The patient was complaining of resting central chest pain for 2 hours prior to admission, but upon arrival, he was pain free. His electrocardiogram showed mild ST-segment depression in the anterior precordial leads. His initial troponin I was elevated at 147 ng/L (normal value <5 ng/L). A two-dimensional transthoracic echocardiogram showed normal left ventricular function. The patient was a smoker and had a history of hypertension. There was no history of diabetes or family history of coronary artery disease. Body mass index was 28 kg/m2.

Given his presentation, the patient underwent an urgent coronary angiogram, which revealed a 50-60% stenosis of the distal left main (LM), 80% stenosis of the ostium of the left anterior descending coronary artery with 90% stenosis of the proximal left anterior descending coronary artery, 60-70% proximal left circumflex stenosis (Figure 1), and mild atheroma of the right dominant coronary artery (Figure 2). His calculated SYNTAX score was 24, and the case was formally discussed in the multidisciplinary team meeting with cardiac surgeons and cardiologists.

Figure 1: Left Coronary Artery

Figure 1

Figure 2: Right Coronary Artery

Figure 2

Based on the findings on the coronary angiogram, which of the following would be the most appropriate treatment strategy for this patient?

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