Case Discussion

[walidhassabala]

A 52-year-old man is evaluated regarding treatment of his coronary artery disease. He had a myocardial infarction 8 years ago and was treated with a coronary stent placed in his right coronary artery. Over the last 8 years he did well with medical therapy, with only mild episodes of exertional angina that resolved with rest or sublingual nitroglycerin. One month ago, he noted worsening of his exertional angina. Coronary angiography showed 50% stenosis of the left main coronary artery, severe disease (75% stenosis) of the left circumflex artery, severe disease (70% stenosis) of the proximal left anterior descending artery, and in-stent restenosis (80%) of the stent within the right coronary artery. Left ventricular systolic function is mildly reduced (ejection fraction, 50%). His medical therapy was increased, and he has remained pain-free with activity. He is active and is a construction worker.

Medical history is notable for diabetes mellitus, hyperlipidemia, and hypertension. Current medications are aspirin, ramipril, atorvastatin, metoprolol, isosorbide mononitrate, diltiazem, and metformin.

Physical examination shows a well-developed man who appears comfortable. Blood pressure is 110/60 mm Hg and heart rate is 60/min. BMI is 28. Neck examination demonstrates a right carotid bruit and no jugular venous distention. Cardiac examination reveals normal heart sounds and no murmurs. Lungs are clear bilaterally and there is no peripheral edema.