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.
Figure 1
Figures 2-4
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?
Show Answer
The correct answer is: D. Functionally complete revascularization with PCI or CABG combined with guideline-directed medical therapies.
Discussion
Guideline-directed medical therapy is indicated for all patients with established coronary artery disease. Angiography (anatomic-based risk stratification) was performed given the patient's symptoms (with demonstrable severe ischemia) at a low workload for his age.
This patient has a severe distal RCA lesion with localizing ischemia in this region, but also has prognostically important multivessel disease (particularly involving the proximal LAD). Although the stress perfusion study did not demonstrate ischemia in the LAD distribution, it is not uncommon for non-quantitative stress perfusion testing to underestimate areas of regional ischemia in patients with multivessel disease. While revascularization of the culprit RCA is clearly indicated, numerous studies of complete vs. incomplete revascularization for patients with multivessel disease support a strategy of complete revascularization for these patients. In a recent meta-analysis amalgamating 35 largely non-randomized studies (including post-hoc analyses of randomized trials), there was a 29% relative reduction in long-term mortality and a 22% relative reduction in myocardial infarction with complete compared with incomplete revascularization.2
Repeat ischemic testing could be performed following revascularization of the RCA, but in general it is not recommended to perform routine stress testing following revascularization, especially when the revascularization strategy (i.e. which vessels to revascularize) can readily be determined up front at the time of angiography, either through traditional angiographic approaches or by the additional use of fractional flow reserve.1 The RCA territory is clearly ischemic and fractional flow reserve is not required for this stenosis particularly given the perfusion stress test results. It is debatable whether fractional flow reserve is required for the LAD stenosis that is angiographically severe, given the high correlation between a truly severe stenosis and FFR<0.80.3
Based on a heart team discussion (including discussion of a hybrid approach), a low SYNTAX score, and ultimately patient preference, the patient was treated with a PCI-based strategy of complete revascularization. He underwent successful RCA PCI followed by IVUS-guided PCI of the LAD and second diagonal branch, all with drug-eluting stents to minimize the risk of repeat revascularization procedures. The obtuse marginal branch was deemed up front in the heart team discussions to be a small vessel with diffuse disease (poor distal runoff and additionally deemed non-bypassable) and as a result was treated medically, rather than attempting to perform PCI on this branch.
The patient has done well, is asymptomatic on metoprolol alone, and is currently enrolled and participating in a cardiac rehabilitation program.
References
Tonino PAL, De Bruyne B, Pijls NHJ et al. Fractional Flow Reserve versus Angiography for Guiding Percutaneous Coronary Intervention. N Engl J Med 2009;360:213-224.
Garcia S, Sandoval Y, Roukoz H et al. Outcomes after complete versus incomplete revascularization of patients with multivessel coronary artery disease: a meta-analysis of 89,883 patients enrolled in randomized clinical trials and observational studies. J Am Coll Cardiol 2013;62:1421-31.
Tonino PA, Fearon WF, De Bruyne B et al. Angiographic versus functional severity of coronary artery stenoses in the FAME study fractional flow reserve versus angiography in multivessel evaluation. J Am Coll Cardiol 2010;55:2816-21.
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