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

A 60-year-old man is evaluated for a 5-month history of exertional chest discomfort that improves with rest. His symptoms have progressively worsened such that he has reduced his activity to a minimum. Medical history is significant for hypertension and hyperlipidemia. Medications are low-dose aspirin, losartan, hydrochlorothiazide, and atorvastatin.

On physical examination, the patient is afebrile, blood pressure is 122/71 mm Hg, and pulse rate is 74/min. Cardiac examination shows a normal S₁ and S₂. A grade 2/6 crescendo-decrescendo systolic murmur is heard best at the upper sternal border with no radiation. Lung examination is normal.

A stress echocardiogram shows 2-mm ST-segment depression at peak stress, normal left ventricular function at rest, normal valvular function, and anterior hypokinesis at peak stress (normal at rest). A 5.4-cm ascending thoracic aortic aneurysm is noted at the level of the sinuses of Valsalva. Coronary angiogram reveals 80% stenosis of the left main coronary artery bifurcation with no significant disease of the left anterior descending, left circumflex, or right coronary arteries.

Which of the following is the most appropriate next step in the patient’s management?

A. Coronary artery bypass graft surgery
B. Metoprolol and isosorbide mononitrate
C. Percutaneous coronary intervention
D. Simultaneous coronary artery bypass graft surgery and aortic repair

MKSAP Answer and Critique

The correct answer is D: Simultaneous coronary artery bypass graft surgery and aortic repair.

The most appropriate management of this patient is simultaneous coronary artery bypass graft (CABG) surgery and aortic repair. On the basis of his angiographic findings (80% stenosis of the left main coronary artery bifurcation), he should undergo revascularization with CABG surgery. In patients with an ascending aorta or aortic root greater than 4.5 cm in diameter who require CABG surgery or surgery to repair valve pathology, aortic repair should be performed at the time of cardiac surgery. Anatomic imaging, such as CT angiography or magnetic resonance angiography, is recommended to plan for open aortic repair before the surgical procedure.

Patients with left main coronary artery disease have traditionally been treated with CABG surgery; however, because this patient has concomitant thoracic aortic aneurysmal disease, CABG surgery without aortic repair is not the best management option.

Patients with established coronary artery disease benefit from optimal medical therapy, including β-blockers and long-acting nitrates. However, given this patient’s thoracic aortic aneurysm and severe coronary artery disease, optimal medical therapy in the absence of revascularization and aortic repair is inappropriate.

Percutaneous coronary intervention is not encouraged for patients with complex disease of the left main coronary artery, especially in the presence of a thoracic aortic aneurysm.

Key Point

• In patients with a thoracic aortic aneurysm greater than 4.5 cm in diameter who require coronary artery bypass graft surgery or surgery to repair valve pathology, aortic repair should be performed at the time of cardiac surgery.

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