Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

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.

Which of the following is the most appropriate treatment for this patient?

A) Coronary artery bypass graft surgery
B) Enhanced external counterpulsation
C) Percutaneous coronary intervention
D) Start ranolazine

MKSAP Answer and Critique

The correct answer is A) Coronary artery bypass graft surgery. This item is available to MKSAP 15 subscribers as item 2 in the Cardiovascular Medicine section.

This patient has several indications for coronary artery bypass graft surgery. He has stenosis of the left main coronary artery and multivessel coronary artery disease with mildly reduced left ventricular systolic function. Coronary artery bypass grafting is indicated in patients with left main coronary artery disease, severe three-vessel disease with reduced left ventricular systolic function, and severe three-vessel disease with involvement of the proximal left anterior descending artery. In addition, patients with diabetes mellitus and multivessel disease also derive benefit from coronary artery bypass graft surgery. In this setting, surgery would not only relieve angina and improve quality of life, but it would also prolong life expectancy. Patients achieve a significant clinical benefit when the left internal mamillary artery graft is used as the bypass conduit for lesions within the left anterior descending artery system.

Enhanced external counterpulsation (EECP) is an acceptable treatment for patients with medically refractory angina who are not candidates for revascularization. However, the patient presented is a candidate for coronary artery bypass graft surgery, and this should be performed prior to considering alternative options such as EECP.

Although percutaneous coronary intervention may occasionally be used for patients with multivessel coronary artery disease who are not appropriate candidates for surgery, it would not be the best choice for this patient. This patient is young and active, and he does not have any clear contraindications for surgery.

Ranolazine can be useful in patients with chronic stable angina on maximal medical therapy. However, this patient has severe obstructive coronary artery disease that requires revascularization. In patients who have failed to benefit from revascularization and remain symptomatic on maximal medical therapy, ranolazine can be considered.

Key Point

• Coronary artery bypass graft surgery is recommended for patients with diabetes mellitus and multivessel disease.

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