Alternative Therapies for a Patient With Refractory Angina | Patient Case Quiz

A 79-year-old male presents to the clinic with recurrent angina. He had undergone coronary artery bypass surgery 16 years ago and multiple percutaneous interventions since then. Past medical history includes hypertension, dyslipidemia, and mild chronic obstructive pulmonary disease. He reports limiting chest discomfort with simple daily activities over the past four months. His medications include carvedilol, lisinopril, isosorbide mononitrate, ranolazine, and amlodipine at maximum tolerated doses. In the clinic, his blood pressure is 101/58 mmHg. He is in sinus rhythm with a heart rate of 62 beats per minute. Patient is referred for selective coronary and bypass angiography which reveals patent internal mammary artery graft to the left anterior descending artery, patent vein grafts to distal right coronary artery and the first obtuse marginal branch. Stents in the first diagonal and second marginal branches are also patent. However, the distal segments of the left anterior descending, posterior descending, and marginal branches are small in caliber and exhibit severe diffuse disease. Left ventricular ejection fraction is 40%.

Which of the following is the least appropriate therapy for his refractory angina?

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