How will you treat this patient?

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joti

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54 yr old with history of DM, Dyslipidemia, chronic smoker admitted with exertional dyspnea.

TTE showed no wall motion abnormalities and EF of 67.6%
LHC showed
LMCA: normal
LAD: branch of second diagonal totally occluded at ostium and is retrogadely getting filled from second diagonal. Otherwise normal.

LCx: Non dominant and shows total occlusion in the mid part with faint antegrade flow. Collaterals to LCX are seen from septal branches of LAD.

RCA: mild disease 40-50%. Collaterals to LCX are from RCA.

No history of MI, PCI, CABG.

What is the best diagnostic/treatment option for this patient?

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Medical mgmt; optimize CAD meds/statin/anti-HTNsives, glycemic control, smoking cessation.

W/u possible COPD or reactive airway disease (PFTs c spirometry + bronchodilators, walking O2 assessment)
 
Thanks Crosnmafingers

Can we derive the managment decision from the OATS trial published in NEJM? This is for my uncle. The Cardiologist is recommending PTCA.

Good luck for your interest.
 
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OAT among others... I don't think you could find one good trial to support intervening on your uncle. Frankly, I don't think his symptom is cardiac either.

Anyway, good luck to him.
 
The symptoms probably aren't cardiac, but given those cath results and his hx of dm, its still a posibility. I would pursue pulmonary w/u and medical optimization, but especially if negative pulm w/u would do an exercise perfusion stress to assess if some of those collateralized areas are exercise limited, and if so would consider intervening appropriately (if possible).

The OAT trial doesn't really apply here... from what you described your uncle never infarcted, and we haven't clearly established that the symptoms aren't anginal yet. Besides, the point is that he may be symptomatic, its less relevant that there may not be a mortalit benefit to pci in this case.
 
...The Cardiologist is recommending PTCA.

Good luck for your interest.

I agree with Myostatin that you can't exclude a cardiac etiology of exertional dyspnea in this patient. He certainly has coronary artery disease, though the ischemic burden is difficult to assess without reviewing the angiograms directly. Even still, diabetics (especially with hypertension) can have marked diastolic disease beyond macrovascular epicardial coronary disease. It might be difficult to tease out the pulmonary vs. cardiac vs. combined etiologies for DOE in this chronic smoker. In addition to PFTs and exercise/pharm perfusion imaging, a few additional thoughts come to mind.

On his ECHO, was there any evidence of valvular disease? What was the size of his atria? Any other evidence of increased left atrial pressures or diastolic abnormality (like on mitral inflow pattern and tissue doppler)? Did he have any TR, and if so, any evidence of pulmonary hypertension?

The LCx is reportedly nondominant and totally occluded (TO). PCI of a TO is generally higher risk with lower probs of success. Seems like a long run for a short slide. Like Myostatin said, this intervention would not be for mortality benefit, but symptom relief. Better be sure the symptoms are coming from ischemia in this territory.

Your uncle sounds like a lot of the veterans I take care of. He should definitely be on ASA, nitrates, high dose statins, and smoking intervention. Try B-blocker (may be difficult with COPD). Even if the symptoms are cardiac, I would make sure that they are causative and limiting, and i would have a VERY HIGH threshold for revasc.

Hope your unc gets better.
 
Treadmill Echo or Dobutamine echo, if can reproduce symptoms and have territorial ischemia/WMA in LAD or LCx territory might have case for trying to dynamite open some of that old calcified plaque. or try EECP. If provocative testing is negative, try inhalers.
 
rather than stress echo, I would advocate a cardiac MRI adenosine stress test if possible. This test will more accurately define wall motion (COPD may have made echo windows technically difficult), definitively reveal any evidence of MI as well as give a good representation of significant ischemic burden.
If he already has infarct greater than 50% in a territory with cad, there is no point in placing a stent in that coronary. Additionally, the image quality of cardiac MRI is so much better than echo showing your uncle the images and explaining whats going on may make him more compliant with whatever treatment he receives.
Just make sure you have access to a good cardiac MRI service (preferable one that allows cardiologists to read as well as radiologists).
 
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