For Completeness Sake: Complete vs. Incomplete Revascularization, a Meta-Analysis
The patient is a 54-year-old male, active smoker (one pack per day for over 30 years despite attempts to quit) with a history of known coronary artery disease that was previously stable and asymptomatic. He presented with an episode of new onset chest pressure with exertion a few days ago that has now abated.
He described the symptoms as sub-sternal chest pressure radiating to the bilateral arms associated with shortness of breath. The pressure started when he was walking and improved with rest; he is currently symptom-free but has restricted his activity for fear of precipitating these symptoms. The symptoms were not associated with nausea, vomiting, diaphoresis syncope, or pre-syncope. The patient also denies orthopnea, paroxysmal nocturnal dyspnea, or lower extremity edema.
The patient's home medications included aspirin, metoprolol, and rosouvastatin.
On physical exam, the patient had a heart rate in the 50s and a blood pressure of 130/80 (symmetric pressures bilaterally). The remainder of his exam was unremarkable. His outpatient ECG is shown below (Figure 1). An echocardiogram demonstrated an ejection fraction of 50-55% with inferobasal hypokinesis.
Amlodipine was added to his regimen and the patient was referred for exercise perfusion stress testing, which demonstrated severe reversible ischemia inferiorly and 3 mm ST-segment depressions in the inferior leads; the patient had chest pain at five minutes of a Bruce protocol that persisted for 20 minutes following completion of the stress test.
Based upon these findings, the patient then underwent diagnostic coronary angiography, which demonstrated relatively focal multivessel disease with a hazy severe lesion in the distal RCA as well as a severe eccentric proximal LAD stenosis and an occluded small caliber obtuse marginal branch (Figures 2-4).
What is the next best step in management of the patient's coronary disease?