A 70-year-old man arrives via emergency services with an acute inferior MI. Despite hypertension and hyperlipidemia, he is physically fit, not diabetic, and has normal renal function. A drug-eluting stent is placed in his dominant right coronary artery. At the time of primary angioplasty, bystander disease is detected at the LAD\/D1 junction, involving both vessels. The D1 stenosis is as severe as the LAD stenosis (\u224880%).<\/p>\n
A dobutamine stress echocardiogram, performed as an outpatient about a month later, is clearly positive for ischemia in the LAD and diagonal territories, and the patient experiences some chest discomfort at peak stress. An exercise stress test is not performed. The patient is asymptomatic during activities of daily living and denies having any angina.<\/p>\n
Questions:<\/strong> Response:<\/strong><\/p>\n James Fang, MD<\/a><\/p>\n September 10, 2012<\/em><\/p>\n Aggressive medical therapy with lipid management, beta-blockade, ACE inhibition, aspirin, and other antianginals, as well as cardiac rehabilitation, should be the cornerstone of this patient\u2019s management. The COURAGE<\/a> and BARI-2D<\/a> trials support this practice as safe and effective.<\/p>\n However, in an \u201casymptomatic\u201d patient, the issue of survival benefit becomes primary. Some suggest, on the basis of observational studies, that revascularization may be superior to optimal medical management if relief of the ischemic burden is substantial (e.g., 10%-20% of the myocardium). Furthermore, exercise-related parameters such as those included in the Duke treadmill score are also useful in assessing prognosis from the CAD burden. Therefore, an exercise stress test should be performed to better define the ischemic threshold, territory at risk, and any symptoms. If there are high-risk features of the exercise stress test, the patient should be offered revascularization as adjuvant therapy to achieve a mortality benefit.<\/p>\n Deciding between PCI versus CABG for bifurcation LAD disease is highly individualized and depends greatly on the expertise of the surgeon or interventionalist, the technical nature of the anatomy, the patient\u2019s comorbidities, and\u00a0patient and physician preferences. At our institution, the coronary anatomy would be reviewed by both surgeon and interventionalist as to their technical ability to treat the disease. Interventionalists routinely address complex bifurcation disease, but the spectrum of comfort and expertise can range widely.<\/p>\n The 2009 Appropriateness Use Criteria for Revascularization<\/a> recommend revascularization either for advanced symptoms or a large ischemic burden, even in the absence of significant symptoms. However, many asymptomatic clinical scenarios when the ischemic burden is intermediate received uncertain recommendations for appropriateness, so clinical judgment becomes paramount.<\/p>\n
\n1. Do you manage the patient medically?
\n2. Do you stent his LAD coronary artery?
\n3. Do you offer him a left-internal mammary artery bypass graft to his LAD?<\/p>\n