A 75-year-old Caucasian man with hypertension, hyperlipidemia, diabetes mellitus II and previous myocardial infarction presents to the cardiovascular medicine clinic for evaluation of stable angina. He is already on maximum doses of long-acting nitrate, ranolazine and a beta-blocker. He continues to have angina and his activity is extremely limited. His heart rate is 52 beats/min and his blood pressure is 95/60 mm Hg. His cardiopulmonary examination is normal. Stress testing with myocardial perfusion imaging is performed and reveals an exercise-induced reversible defect in the inferior wall. The left ventricular ejection fraction is normal. Coronary angiography reveals a long occlusion of the mid right coronary artery that fills via collaterals from the left anterior descending coronary artery. There is no significant disease elsewhere. You consider other options for his management as he is already on maximal medical therapy.
Which of the following statements regarding revascularization options is correct?
The correct answer is: D. According to the COURAGE trial, PCI plus optimal medical therapy was no more effective than optimal medical therapy in preventing mortality or myocardial infarction in patients with stable coronary artery disease (CAD).
Transmyocardial laser revascularization (TMLR) is based on the use of a high powered carbon dioxide laser that interjects a strong energy pulse into the left ventricle and creates a transmural channel and was once thought to be a modality for managing surgically untreatable CAD. Although the results of several large clinical studies show marked improvements in angina, exercise tolerance and improvement in regional myocardial perfusion, the reported mortality (7-10%) following TMLR is a significant cause for caution. Moreover, study findings have not been uniform in terms of confirming improved myocardial perfusion with thallium scintigraphy and defining major differences in short-term morbidity and mortality; therefore, TMLR has fallen out of favor. There is no benefit in revascularization of an adequately collateralized vessel. Addition of long acting nitrate is appropriate if tolerable. Option D is correct.