A 61-year-old man with a past medical history significant for hypertension, hyperlipidemia (LDL-C, 145 mg\/dL; HDL-C, 38 mg\/dL), and type 2 diabetes (HbA1c, 8.2) presents to his primary care physician after several months of exertional chest tightness that\u00a0is associated with dyspnea and relieved by rest. His current medications include lisinopril at 20 mg\/day, metoprolol succinate at 50 mg\/day, simvastatin at 20 mg\/day, and glyburide at 10 mg\/day.<\/p>\n
He is referred for an exercise treadmill test with myocardial perfusion imaging. He exercises for 8:08, achieving 10.2 METs and reaching 94% of peak HR goal, before stopping for mild chest tightness and fatigue. The imaging portion of the study\u00a0reveals an estimated LVEF of 62% with moderate-sized, medium-intensity reversible perfusion defects in both the inferior and lateral walls.<\/p>\n
Based on these results, the patient is referred for coronary angiography, which reveals\u00a070% discrete lesion of the mid-LAD<\/a> after the take-off of the first diagonal, 90% complex lesion of the mid-LCx<\/a>, and 80% discrete lesion in the proximal RCA<\/a>.<\/p>\n Questions for Discussion:<\/strong><\/p>\n 1.\u00a0\u00a0 How would you proceed at this point?<\/p>\n 2.\u00a0\u00a0 What would constitute \u201coptimal medical therapy\u201d for this patient?<\/p>\n 3.\u00a0\u00a0 Based on the patient\u2019s clinical presentation, would you have performed the sequential testing as outlined in the vignette (i.e., stress test followed by coronary angiography), or would you have pursued a different management strategy?<\/p>\n Response: Therapy for this patient is very much dependent on the goals of the patient as well as his physicians. Clearly, medical therapy needs to be intensified. The decision to catheterize the patient based on the stress test results would likely have been driven by a concern for multivessel ischemic heart disease, despite the good exercise tolerance, and by a perception that revascularization in this setting (with preserved ventricular function) improves survival. This decision of whether or not to revascularize depends on the ischemic burden. If the patient is not satisfied with his functional capacity and is limited by angina, I would offer revascularization. Contemporary revascularization trials suggest no significant mortality differences between CABG and PCI, even in the presence of DM. However, more procedures are likely with a PCI approach.<\/p>\n Medical management should consist of aggressive statin therapy to drive his LDL to <70 mg\/dL, his HDL to >40 mg\/dL, and his TG to <200 mg\/dL. I suspect a potent statin will be necessary to achieve these levels \u2014 and if that isn\u2019t effective, I would consider niacin, even though the trial results aren\u2019t in yet. His HbA1c goal is unclear, particularly in light of the recent ACCORD data<\/a>. I would personally target <7.5%, but this is a compromise based on the available data. Clearly, overly aggressive control has to be balanced against complications from hypoglycemia \u2014 an issue that has tempered the trials of glucose control in heart disease. The best way to control blood sugar is not clear from the diabetes trials, and most patients seem to require more than one class of oral hypoglycemic drug to reach good control. Finally, this patient\u2019s beta-blocker dose is very modest and could be increased.<\/p>\n A case could certainly have been made to manage the patient medically, based purely on the stress test results. However, in the U.S., it is rare for a positive stress test to not lead to coronary angiography, despite good evidence that even patients with multivessel ischemic heart disease can be managed medically without sacrificing years of life.<\/p>\n","protected":false},"excerpt":{"rendered":" A 61-year-old man with a past medical history significant for hypertension, hyperlipidemia (LDL-C, 145 mg\/dL; HDL-C, 38 mg\/dL), and type 2 diabetes (HbA1c, 8.2) presents to his primary care physician after several months of exertional chest tightness that\u00a0is associated with dyspnea and relieved by rest. His current medications include lisinopril at 20 mg\/day, metoprolol succinate […]<\/p>\n","protected":false},"author":514,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1,9],"tags":[],"class_list":["post-1321","post","type-post","status-publish","format-standard","hentry","category-general","category-interventional-cardiology"],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/1321","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/users\/514"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/comments?post=1321"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/1321\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/media?parent=1321"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/categories?post=1321"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/tags?post=1321"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}\n
\n<\/strong>James Fang, MD<\/strong><\/a><\/p>\n
![70% discrete lesion of the mid-LAD<\/a> after the take-off of the first diagonal,](\"http:\/\/orbital.cardioexchange.org\/uploads\/blogs\/images\/CaseDiscussions\/DMcase\/Picture2.jpg\"){kind=link}
![90% complex lesion of the mid-LCx<\/a>, and](\"http:\/\/orbital.cardioexchange.org\/uploads\/blogs\/images\/CaseDiscussions\/DMcase\/Picture1.jpg\"){kind=link}
![80% discrete lesion in the proximal RCA<\/a>.<\/p>\nQuestions for Discussion:<\/strong><\/p>\n1.\u00a0\u00a0 How would you proceed at this point?<\/p>\n\nOptimize medical therapy with intensification of glycemic, anti-hypertensive, and lipid-lowering therapies.<\/li>\nOptimize medical therapy but also proceed with PCI and stenting of the RCA and LCx.<\/li>\nOptimize medical therapy and proceed to PCI based on fractional flow reserve assessment.<\/li>\nOptimize medical therapy and refer the patient for CABG surgery.<\/li>\n<\/ul>\n2.\u00a0\u00a0 What would constitute \u201coptimal medical therapy\u201d for this patient?<\/p>\n3.\u00a0\u00a0 Based on the patient\u2019s clinical presentation, would you have performed the sequential testing as outlined in the vignette (i.e., stress test followed by coronary angiography), or would you have pursued a different management strategy?<\/p>\nResponse:\n<\/strong>James Fang, MD<\/strong><\/a><\/p>\nTherapy for this patient is very much dependent on the goals of the patient as well as his physicians. Clearly, medical therapy needs to be intensified. The decision to catheterize the patient based on the stress test results would likely have been driven by a concern for multivessel ischemic heart disease, despite the good exercise tolerance, and by a perception that revascularization in this setting (with preserved ventricular function) improves survival. This decision of whether or not to revascularize depends on the ischemic burden. If the patient is not satisfied with his functional capacity and is limited by angina, I would offer revascularization. Contemporary revascularization trials suggest no significant mortality differences between CABG and PCI, even in the presence of DM. However, more procedures are likely with a PCI approach.<\/p>\nMedical management should consist of aggressive statin therapy to drive his LDL to <70 mg\/dL, his HDL to >40 mg\/dL, and his TG to <200 mg\/dL. I suspect a potent statin will be necessary to achieve these levels \u2014 and if that isn\u2019t effective, I would consider niacin, even though the trial results aren\u2019t in yet. His HbA1c goal is unclear, particularly in light of the recent ACCORD data<\/a>. I would personally target <7.5%, but this is a compromise based on the available data. Clearly, overly aggressive control has to be balanced against complications from hypoglycemia \u2014 an issue that has tempered the trials of glucose control in heart disease. The best way to control blood sugar is not clear from the diabetes trials, and most patients seem to require more than one class of oral hypoglycemic drug to reach good control. Finally, this patient\u2019s beta-blocker dose is very modest and could be increased.<\/p>\nA case could certainly have been made to manage the patient medically, based purely on the stress test results. However, in the U.S., it is rare for a positive stress test to not lead to coronary angiography, despite good evidence that even patients with multivessel ischemic heart disease can be managed medically without sacrificing years of life.<\/p>\n","protected":false},"excerpt":{"rendered":"A 61-year-old man with a past medical history significant for hypertension, hyperlipidemia (LDL-C, 145 mg\/dL; HDL-C, 38 mg\/dL), and type 2 diabetes (HbA1c, 8.2) presents to his primary care physician after several months of exertional chest tightness that\u00a0is associated with dyspnea and relieved by rest. His current medications include lisinopril at 20 mg\/day, metoprolol succinate […]<\/p>\n","protected":false},"author":514,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1,9],"tags":[],"class_list":["post-1321","post","type-post","status-publish","format-standard","hentry","category-general","category-interventional-cardiology"],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/1321","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/users\/514"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/comments?post=1321"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/1321\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/media?parent=1321"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/categories?post=1321"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/tags?post=1321"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}](\"http:\/\/orbital.cardioexchange.org\/uploads\/blogs\/images\/CaseDiscussions\/DMcase\/Picture3.jpg\"){kind=link}