Between a Rock and a Hard Place: AUC to the Rescue?

A 70-year-old, highly functional female was referred to a pulmonologist for consideration of biopsy of a lung mass discovered on a chest x-ray to work up chest pain. On further detailed history, she revealed that the chest discomfort was sub-sternal and consistently happened with emotional stress or walking up hill for the last several months. She had a past history of smoking. She was not taking aspirin, nitroglycerin or beta-blockers. She was referred for a stress echo for further evaluation.

On echocardiography, at rest her LV function was normal without any regional wall motion abnormalities or significant valve disease. During the exercise stress test, she developed chest pain at three minutes of the Bruce protocol. The test had to be terminated at six minutes because of continued chest pain, which resolved quickly in recovery. EKG showed 2 mm inferolateral ST depression during exercise. Immediately post stress echocardiography showed akinesis of the distal anterior wall, apex and distal anterior septum. The posterior and lateral wall became hypokinetic. The inferior wall augmented normally with exercise. Compared with rest images, the LV cavity was noted to dilate post stress (Video Clip 1 and Video Clip 2).

Given these findings, the patient was immediately seen by a cardiologist who initiated aspirin and referred her for cardiac catheterization. Cardiac catheterization revealed a 99% proximal left main coronary artery lesion with no significant obstruction in the distal left vessels. The right coronary artery had no significant obstruction (Video Clip 3 and Video Clip 4).

What should be the next step in the management of this patient?

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