A 62-Year-Old Man Presents With Three-Months of Throat Pain

He is active and has enjoyed excellent general health except for mild depression and gastroesophageal reflux disease. Three months ago, he developed throat discomfort when walking more than four minutes on level ground, without other symptoms. He also had one episode of throat discomfort with emotional stress. He saw his primary care physician and was referred for treadmill exercise stress testing. He completed 9 minutes and 59 seconds of the Bruce protocol to a peak heart rate of 90% predicted and blood pressure of 166/86 (12 METS), stopping due to his typical throat discomfort that began 4 minutes and 6 seconds into exercise. His ECG evolved 2-3 mm horizontal to upsloping ST-segment depressions in an inferior-apical distribution on a substrate of right bundle-branch block. Three-days later, he underwent repeat treadmill exercise testing with myocardial perfusion imaging (MPI), completing 10 minutes (12 METS). Throat pain began at 4 minutes and 15 seconds of exercise. Perfusion imaging demonstrated a small-to-moderate (not quantified) area of distal septal and apical ischemia without transient ischemic dilation. His left-ventricular systolic function was normal with an ejection fraction of 0.68. Medical therapy was initiated with aspirin 81 mg daily, metoprolol succinate 25 mg daily, and atorvastatin 10 mg daily. He was not previously aware of hyperlipidemia. There was no history of diabetes or hypertension.

He was referred for initial cardiology evaluation four weeks later, over which time he continued with Canadian Cardiovascular Society (CCS) Class III angina (throat discomfort). After discussion of his symptoms, risk, and treatment options, he elected to intensify his medical therapy. The dose of his beta-blocker was increased and long-acting nitrates were added, with additional instructions to use sublingual NTG prior to activities that would predictably precipitate angina. Despite strict heart rate and blood pressure control, his symptoms continued unabated and he expressed a strong preference to proceed with diagnostic angiography in anticipation of revascularization. Findings included right coronary artery dominance with no significant left-main disease, serial 90% proximal and mid left-anterior descending artery (LAD) stenoses, an 80% mid-left circumflex artery (LCx) lesion, and an 80% mid-right coronary artery (RCA) lesion. His coronary artery lesions were described as easily amenable to percutaneous coronary intervention (PCI). The SYNTAX score was not calculated but felt to be in a low-intermediate range. Other medical as well as revascularization options for angiographic three vessel disease were reviewed and discussed. He voiced a strong preference to avoid “open heart surgery.” A final decision was not made on the day of diagnostic angiography and the conversation was continued over the course of the next two days with the patient and members of the multi-disciplinary Heart Team.

At this point, which treatment choice would you recommend?

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