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  #1  
Old 11-01-2011
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Arrow Angina 2

A 69-year-old woman who is a 30-pack-year smoker with non–insulin-dependent diabetes and hypertension comes to your office with complaints of chest pain on exertion for the last 18 months which has had a predictable pattern. Her chest pain always occurs after she walks 2 blocks at a fast pace. She does not have the pain any other time, and denies any other symptoms. Her vital signs are within normal limits. Physical examination is relatively unremarkable. You schedule her for an exercise stress test, which reveals ST segment depression in leads V1, V2, and V3 after 4 minutes of exercise that is reversible with rest. You decide to send her for a cardiac catheterization, which reveals an 80% stenosis of the proximal left main coronary artery. Which of the following is the most appropriate intervention at this time?
A. Prescribe sublingual nitroglycerin as needed for pain and a daily aspirin
B. Reexamine her in 6 months and ask her to stop exercising until then
C. Send her for percutaneous balloon angioplasty
D. Send her for coronary artery bypass grafting
E. Start a beta-blocker and aspirin, and if symptoms persist 1 month after starting this regimen, schedule coronary artery bypass grafting
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  #2  
Old 11-02-2011
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I'd say CABG !!! cause as far as I know , this pt will benefit from revascularization as the left main is involved as it's one of CABG indications !!! not sure though.
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Old 11-02-2011
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Yup i would go with that too also the baloon stent won't do anygood with an 80% stenosis.
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Old 11-02-2011
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D. Send her for coronary artery bypass grafting,80% stenosis of the proximal left main coronary artery being one of the condition for CABG.
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Old 11-02-2011
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The correct answer is D. It is important to know the indication for coronary artery bypass graft (CABG). These are 1. Significant left main coronary stenosis, 2. Left main equivalent: significant (>70%) stenosis of proximal LAD and proximal left circumflex artery, 3. Three-vessel disease (survival benefit is greater when LVEF is <0.50), 4. Two-vessel disease with a significant proximal LAD stenosis and either ,0.50 or demonstrable ischemia on noninvasive testing, 5. One- or 2-vessel coronary artery disease without significant proximal LAD stenosis, but with a large area of viable myocardium and high-risk criteria on noninvasive testing, 6. Disabling angina despite maximal medical therapy, when surgery can be performed with acceptable risk.

Choices A and E are inappropriate because immediate intervention is required.

Reexamination in 6 months (choice B)—or sooner if symptoms worsen—is totally inappropriate because this patient has significant occlusion to one of the most vital arteries to the heart. Immediate intervention is necessary.

Percutaneous coronary intervention (choice C) is widely employed in patients with symptoms and evidence of ischemia due to stenoses of one or two vessels, exclusive of the left main coronary artery, and even selected patients with three-vessel disease.
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Old 11-02-2011
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left main ----> CABG
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