Recurrent CAD in a Young Woman Despite Optimal Medical Therapy and Diligent Cardiac Rehabilitation
Our patient is a 46-year-old Vietnamese woman with an extensive history of cardiovascular disease (CVD) dating back to April 2016. Her past medical history is significant for poorly controlled diabetes, hypertension, and coronary artery disease with multiple coronary interventions. In April 2016, she received percutaneous coronary intervention (PCI) to her right coronary artery (RCA), and the decision was made to treat the diffuse left anterior descending artery (LAD) disease medically. She was initiated in cardiac rehabilitation (CR) and was adherent to this. A few months later, she developed chest pain again and underwent stenting of her distal LAD and proximal circumflex artery. Several months later, she developed recurrent symptoms and received PCI to her proximal RCA. The patient then underwent stenting of her proximal RCA due to recurrent symptoms. Several months later, she received stenting to the distal circumflex and first obtuse marginal due to recurrent chest pain. During her eighth cardiac catheterization within just over 1 year, a new significant obstructive lesion was noted in the distal LAD. Given significantly elevated systemic blood pressure and rapid recurrence of disease despite angiography, the patient underwent medical optimization of her regiment.
On echocardiography, she had no significant valvular disease, no regional wall motion abnormalities, mild increased concentric left ventricular wall thickness, and a normal ejection fraction of 63%.
She was enrolled in CR after her first coronary angiogram and PCI in April 2016. Despite this, her blood pressure remained elevated in the 150-180 mmHg systolic, with poorly controlled blood glucose and a hemoglobin A1c of 8.3%.
Despite an individualized treatment plan and aggressive CR, the patient continued to struggle with significantly uncontrolled diabetes and significantly elevated blood pressures. Additionally, her aggressive early-onset atherosclerosis was extremely concerning. Initially, there were some issues with medication intolerance secondary to severe nausea; however, with the help of CR, she was able to be initiated on an optimal medical regimen. This included aspirin, atorvastatin, clopidogrel, isosorbide mononitrate, losartan, metformin, metoprolol, insulin, and ranolazine. She was seen by medical genetics, who considered the possibility of other connective tissue disorders that may present with aggressive early-onset atherosclerosis; however, genetic testing was negative.
Which of the following statements about cardiac rehabilitation is true?