Video 1 and 2
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A 45-year-old man presented to the emergency department for evaluation of acute onset of chest pain. He reported the acute onset of severe, retrosternal chest pain, with radiation to the left arm. The patient was dyspneic and diaphoretic during the initial episode. The symptoms resolved spontaneously after about one hour.
In the emergency room, the initial electrocardiogram demonstrated non-specific ST segment changes, with T wave flattening in the inferior limb leads. The initial troponin T value was 0.06 ng/mL, with subsequent values of 2.0 ng/mL, then 1.6 ng/mL on serial measurements. He continued to have several mild episodes of chest pain, similar in character to the initial episode. He was started on oral aspirin, ticagrelor, and intravenous unfractionated heparin, and admitted to the cardiology service.
The following day, the patient was referred for coronary angiography, revealing the single origin of the coronary arteries from the right coronary cusp, with the left main coronary artery coursing posterior to the aorta, as seen in the right anterior oblique (RAO) projection (Video 1). The left anterior descending (LAD) artery had a 95% discrete stenosis in the mid-vessel, with TIMI 2 distal vessel flow (Video 2). The left circumflex artery and right coronary arteries had mild, non-obstructive coronary artery disease (CAD). The serum glucose was normal, and transthoracic echocardiography revealed normal left ventricular systolic function.
The correct answer is: C. Percutaneous coronary intervention (PCI) to the left anterior descending artery.
Answer option C is correct because the patient presented with acute chest pain, positive cardiac biomarkers and non-specific changes on 12-lead ECG, which is most consistent with acute coronary syndrome (NSTE-ACS) secondary to atherosclerotic coronary artery disease. Coronary angiography revealed a severe stenosis in the LAD, thus he is a candidate for percutaneous revascularization with stent deployment.1 Answer option D is incorrect because his coronary artery anomaly is a variation that is known to be low risk for sudden cardiac death. When the left main coronary artery arises from the right coronary cusp, the course of the left main artery is important in stratifying the risk to the patient. If the left main takes an intra-arterial course between the pulmonary artery and the aorta, this is associated with a high risk of sudden cardiac death, and surgical intervention is, thus, an accepted treatment. When the course of the left main coronary artery takes a posterior (retroaortic) course, this is associated with a low risk of sudden cardiac death, so the benefit of surgical intervention is low.2 The course of the left main coronary artery can be determined during angiography in the RAO projection (Video 1). For this patient, the benefit of percutaneous revascularization to the culprit LAD stenosis outweighs the surgical intervention to the anomalous coronary. Furthermore, re-implantation of the left main coronary artery alone would not address the patient’s LAD stenosis. Answer option A is incorrect because his atherosclerotic coronary artery disease is limited to a single epicardial vessel, and CABG is, thus, not warranted.3 Answer option B is incorrect because stress myocardial perfusion imaging is contraindicated in the setting of acute coronary syndrome. This patient ultimately underwent successful percutaneous coronary intervention with deployment of a drug-eluting stent in the LAD.
References:
- Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non–ST-elevation acute coronary syndromes: executive summary: report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;64:2645-87.
- Angelini, Paolo. Coronary artery anomalies: an entity in search of an identity. Circulation 2007;155:1296-305.
- 2011 ACCF/AHA guideline for coronary artery bypass graft surgery: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons. J Am Coll Cardiol 2011;58;e123-e210.
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