A 72-year-old man with a history of hypertension, diabetes, hyperlipidemia, and coronary artery disease complicated by a prior inferior myocardial infarction (MI) and coronary artery bypass graft five years ago presents to cardiology clinic for routine follow-up. He is very active and reports an unlimited exercise tolerance. He denies chest pain, dyspnea, or lower extremity edema. He is compliant with his medications which include aspirin 81 mg daily, metoprolol succinate 25 mg daily, lisinopril 5 mg, and crestor 5 mg daily. On exam, he is a well-appearing man with a blood pressure of 147/86 and heart rate of 82 beats per minute. His examination is unremarkable. Routine ECG is ordered and is shown below. It is unchanged from his baseline ECG. A transthoracic echocardiogram obtained two months ago reveals an ejection fraction of 50-55% with akinesis of the basal inferior wall. Recent fasting lipids are notable for an LDL of 107 mg/dL, HDL of 54 mg/dL, and TG 168. He is referred for an exercise nuclear stress test and moderate anterior ischemia is identified. The patient did not have any symptoms during the stress test.
Which of the following statements about this patient is correct?
The correct answer is: B. He requires an increased dose of crestor and uptitration of his metoprolol and/or lisinopril as tolerated.
Review of answer choices:
A. The 2009 appropriate use guidelines1 state that it is reasonable to obtain an exercise or pharmacologic SPECT MPI in asymptomatic patients five years after coronary artery bypass graft.
B. According to the updated ATP III guidelines2 the patient's LDL is currently above goal and should be less than 70 mg/dL since he has both CAD and diabetes. His blood pressure is also above goal and should be less than 140/90.3 Further uptitration of his crestor and either metoprolol and/or lisinopril is needed.
C & D. The observational study by Aldweib et al.4 found that patients with prior coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI) with silent ischemia on routine SPECT MPS who were selected for revascularization did not have lower all-cause mortality when compared to those receiving medical therapy. The nuclear substudy of the COURAGE trial,5 which included patients with silent ischemia and prior revascularization, also did not show a reduction in adverse outcomes (death or MI) following PCI. A few observational studies, however, suggest that revascularization in patients with moderate to severe ischemia with revascularization will reduce death and MI.6,7 The ongoing International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA)8 randomized controlled trial will hopefully give us further insight into this important question by randomizing both asymptomatic and symptomatic patients with at least moderate ischemia, with or without previous revascularization, to PCI plus optimal medical therapy versus optimal medical therapy alone.
Hendel RC, Berman DS, Di Carli MF, et al. ACCF/ASNC/ACR/AHA/ASE/SCCT/ SCMR/SNM 2009 appropriate use criteria for cardiac radionuclide imaging: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the American Society of Nuclear Cardiology, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance, and the Society of Nuclear Medicine. J Am Coll Cardiol 2009;53:2201-29.
Grundy SM, Cleeman JI, Merz CNB, et al. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation 2004;110:227-39.
Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCA/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 2012:18:60:e44-e164.
Aldweib N, Negishi K, Hachamovitch R, et al. Impact of repeat myocardial revascularization on outcome in patients with silent ischemia after previous revascularization. J Am Coll Cardiol 2013;61:1616-23.
Shaw LJ, Weintraub WS, Maron DJ, et al. Baseline stress myocardial perfusion imaging results and outcomes in patients with stable ischemic heart disease randomized to optimal medical therapy with or without percutaneous coronary intervention. Am Heart J 2012;164:243-250.
Hachamovitch R, Hayes SW, Friedman JD, et al. Comparison of the short-term survival benefit associated with revascularization compared with medical therapy in patients with no prior coronary artery disease undergoing stress myocardial perfusion single photon emission computed tomography. Circulation 2003;107:2900-7.
Moroi M, Yamashina A, Tsukamoto K, et al. Coronary revascularization does not decrease cardiac events in patients with stable ischemic heart disease but might do in those who showed moderate to severe ischemia. Int J Cardiology 2012;158:246-52.