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

A 69-year-old man is evaluated during a follow-up visit. He initially presented with a 3-month history of chest pressure and dyspnea that occurred primarily with exertion. Despite maximal medical therapy, his symptoms have not abated and adversely affect his quality of life. Medical history is significant for type 2 diabetes mellitus, hypertension, and hyperlipidemia. Medications are low-dose aspirin; metformin; long-acting nitroglycerin; and optimal doses of metoprolol, lisinopril, ranolazine, and simvastatin.

On physical examination, blood pressure is 128/73 mm Hg, and pulse rate is 60/min. Cardiac examination reveals a normal S₁ and S₂ without an S₃or S₄. There is no lower extremity edema.

Coronary angiogram is significant for a normal left main coronary artery and a 90% stenosis in the proximal left anterior descending artery resulting from ulcerated plaque.

Which of the following is the most appropriate management?

A. β-Carotene
B. Cardiac rehabilitation
C. Percutaneous coronary intervention
D. Ticagrelor

MKSAP Answer and Critique

The correct answer is C. Percutaneous coronary intervention.

This patient with diabetes mellitus and single-vessel coronary artery disease should undergo revascularization with percutaneous coronary intervention (PCI) or coronary artery bypass grafting. PCI has not been shown to be superior to optimal medical therapy in patients with stable angina for reduction of cardiovascular endpoints, such as mortality and myocardial infarction. However, PCI has been associated with improvement in quality of life by reducing the severity and frequency of angina. Current guidelines recommend that diagnostic angiography and PCI be reserved for patients with refractory symptoms while receiving optimal medical therapy, those who are unable to tolerate optimal medical therapy owing to side effects, or those with high-risk features on noninvasive exercise and imaging tests. This patient has 90% stenosis of the proximal left anterior descending artery and refractory symptoms; therefore, PCI is a reasonable therapeutic option.

The use of β-carotene, selenium, chromium, vitamin C, vitamin E, and estrogen has not been associated with improved cardiovascular outcomes or relief of symptoms and is not recommended in patients with ischemic heart disease.

Cardiac rehabilitation may be appropriate after revascularization occurs; however, this patient should first undergo revascularization to treat his crescendo angina symptoms.

Aspirin is associated with a decreased risk for myocardial infarction, stroke, and cardiovascular death in patients with coronary artery disease. Aspirin doses of 81 mg to 162 mg daily are recommended in all patients with established coronary artery disease unless contraindicated. In patients allergic to aspirin, clopidogrel is recommended as an alternative. The use of newer antiplatelet agents (prasugrel, ticagrelor) as monotherapy has not been tested in patients with stable angina. Dual antiplatelet therapy for chronic angina in the absence of stent placement is not recommended.

Key Point

• In patients with stable angina, diagnostic angiography and percutaneous coronary intervention are reserved for patients with refractory angina symptoms while receiving optimal medical therapy, those who are unable to tolerate optimal medical therapy owing to side effects, or those with high-risk features on noninvasive exercise and imaging tests.

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