NEJM -- Management of Stable Coronary Disease

NEJM -- Management of Stable Coronary Disease

Management of Stable Coronary Disease

Case Vignette

A 65-year-old man with hypertension, obesity, and type 2 diabetes mellitus has been under your care for the past 5 years. He has been receiving hydrochlorothiazide (25 mg daily) and metformin (500 mg twice daily); his blood pressure is 130/82 mm Hg, his body-mass index (the weight in kilograms divided by the square of the height in meters) is 32, and his glycated hemoglobin is 7.5%. He comes to your office seeking advice about the management of his recently diagnosed coronary artery disease. Two weeks earlier, he had presented with chest tightness and shortness of breath after walking two blocks. His symptoms resolved within a few minutes at rest. An exercise-tolerance test on a treadmill was performed according to the Bruce protocol, along with myocardial perfusion imaging. The patient exercised for 8 minutes, stopping because of chest pressure and dyspnea; his peak systolic blood pressure was 160 mm Hg, and his peak heart rate was 140 beats per minute. Electrocardiography showed ST-segment depression of 1 mm in the anterolateral leads. The perfusion study revealed a fixed perfusion defect of moderate size in the anterior wall and a reversible defect of moderate size in the anterolateral wall.

The patient underwent cardiac catheterization and was found to have multivessel coronary artery disease, with occlusion of the first diagonal branch of the left anterior descending coronary artery, a long lesion with 70% stenosis in the midportion of the left anterior descending coronary artery, 80% stenosis with a calcified lesion in the proximal left circumflex coronary artery, and 50% stenosis of the posterior descending coronary artery. A left ventriculogram obtained during the procedure showed anterior-wall hypokinesis and a left ventricular ejection fraction of 45%. The patient was advised to discuss management of his coronary artery disease with you before making a decision about how to proceed; you have received the results of his exercise test and his catheterization report.