Severe right coronary artery stenosis
49-year-old-male complained of a feeling of oppression behind the sternum, always when there was emotional stress. His coronary CT showed Severe high level stenosis with wall irregularities of the right coronary artery. The treatment options are coronary revascularization procedure versus optimized pharmacologic management.
49 years old, male
- There have been some significant alarming symptomatic signs in this gentleman and I would suspect that he might sustain somewhat more severe coronary artery disease (CAD) in relation to the non-invasive cardiac findings.
- It seems that between the year 2005 to 2009 there is an accelerated atherosclerotic course of the RCA disease. Rapid plaque expansion might be a surrogate morphological marker for "vulnerable plaque" and thus I would not want to wait for the "next symptomatic episode" which may be unpredictable in this patient.
- This is an active, relatively young executive gentleman, and I would discuss with him the possibility of undergoing a coronary angiography for those aforementioned reasons. Nonetheless, I would present the matter to him in a balanced fashion (this is not a "black or white type of recommendation") with my tendency to recommend on elective coronary angiography over the next few weeks.
- During the course of coronary angiogram, additional diagnostic measures could be undertaken in order to enhance the diagnostic capacity of the test. Those measures could include the performance of a coronary physiologic test (e.g. FFR=fractional flow reserve) and/or intra-coronary ultrasonic imaging (IVUS) if the angiographic findings are not conclusive about the need for revascularization.
- If indeed the patient would become a candidate for a percutaneous revascularization procedure, the fact he is allergic to aspirin plays a major and restrictive role here as it limits the percutaneous revascularization strategy towards optimized POBA (i.e. balloon or cutting balloon) or one of the new generation of bare metal stents (BMS) utilization. Due to the ASA allergy I would probably not consider to use a drug eluting tent (DES) in this case. Regardless, I would advise to better define the term "aspirin sensitive" in this case.
- I am not aware of the patient's lipid profile and/or hs-CRP levels. Those measures should be drawn and I would probably recommend to initiating a statin management, using for example Crestor (Resuvastatin) @20 mg daily and pending on the LDL profile (aiming to get it down towards 70 mg/dl while monitoring potential enzymatic and/or clinical side-effects).
- Cardiac CTA can not detect plaque stability thus I would not rely on this modality to conclude whether the plaque is stable or not. Nonetheless, as stated above, there is an indicator here for accelerated atherosclerotic course of the RCA disease which might indicate that the plaque is indeed "vulnerable or accelerated" but this is a speculative (albeit clinically relevant) conclusion.
- Since the patient previously reported on exacerbation of angina secondary to emotional stress and accelerated hypertensive events, I would highly recommend on adding a beta blocker medication to his treatment. I would start with a selective β1 antagonist such as Bisoprolol Fumarate 2.5 mg/daily and monitor for heart rate and blood pressure.
- Considering the term "surgical treatment", I presume it refers to a surgical coronary revascularization procedure (i.e. bypass surgery). I would advise first to establish a precise diagnosis and define the pathology during the course of a coronary angiography and only then to determine the appropriate revascularization strategy in this case.
- To the best of our current knowledge, the risk for cardiovascular mortality would not differ with the adoption of those 2 strategies (angioplasty vs. medical management), pending upon optimization of the medical management (e.g. statin and beta-blocker management as specified above).
- The risk of myocardial infarction is unpredictable (probably in the range of 2-3%/year) and thus could not necessarily be altered in favor of one approach over the other.
- The risk for accelerating angina might be better managed using angioplasty but this statement should be taken with cautious due to: 1) ambiguous coronary diagnosis so far, 2) need for an 'upgraded' medical (pharmacologic) management, 3) the fact that this patient has an unpredictable pattern of angina which is not too often and/or severe. Thus, optimized pharmacologic management is certainly a legitimate strategy here prior to adopting a more 'invasive' strategy.