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Old 11-01-2011
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Arrow Angina

A 55-year-old man has progressive, unstable, disabling angina that does not respond to medical management. His father and 2 older brothers died of heart attacks before the age of 50. The patient stopped smoking 20 years ago, but has a sedentary lifestyle, is a bit overweight, has type II diabetes mellitus, and has high cholesterol concentrations. Cardiac catheterization demonstrates 70% occlusion of 3 coronary arteries, including the anterior descending, with good distal vessels. His left ventricular ejection fraction is 55%. Which of the following is the best therapy for this man?
A. Angioplasty and stenting of all affected vessels
B. Continued medical management until occlusion levels exceed 90% or ejection fraction becomes less than 35%
C. Intensive medical therapy to bring his ejection fraction to more than 85% and allow surgical coronary revascularization
D. Triple coronary bypass using the internal mammary artery for the anterior descending graft, and saphenous vein for the others
E. Triple coronary bypass using saphenous vein for all the grafts
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Old 11-02-2011
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I'm thinking d ????!!!
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  #3  
Old 11-02-2011
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D also... i onow we use the internal mammary artery for a graft
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Old 11-02-2011
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D. Triple coronary bypass using the internal mammary artery for the anterior descending graft, and saphenous vein for the others
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Old 11-02-2011
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The correct answer is D. There is a clear indication for intervention, with progressive angina. With multiple vessels involved, the surgical option is better than angioplasty. The most critical graft should be done with the best available conduit, which is the internal mammary artery.

Angioplasty and stenting (choice A) is better suited for isolated vessels rather than multiple ones.

Seventy percent occlusion already is an indication for intervention, and it should be done before ventricular function deteriorates. Continued medical management until occlusion levels exceed 90% or ejection fraction becomes less than 35% (choice B) delays treatment until occlusion becomes more critical, or until ventricular damage precludes surgery.

The patient described has a normal ejection fraction. It could never become 85%, as suggested in choice C.

Using the saphenous vein (choice E) is the next best answer, which would be appropriate if for some reason the internal mammary artery were not available
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