Coronary Revascularization for Myocardial Ischemia

An 80-year-old woman with a history of hypertension and hyperlipidemia presents to her primary care physician for a routine examination and is noted to have a right-sided carotid bruit. Her physician orders a carotid ultrasound that demonstrates an 80% stenosis. She has no symptoms of amaurosis fugax, focal limb weakness, sensory changes, or slurred speech. She is referred for carotid endarterectomy and the surgeon requests a preoperative risk stratification by a cardiologist. On presentation to the cardiologist, she reports no history of chest discomfort with exertion or at rest. She does note some shortness of breath that seems to be limiting her physical activity during the past 6 months. There are no changes on her resting electrocardiogram suggestive of ischemia or infarct. Given symptoms of arthritis that also limit her physical activity, she undergoes a pharmacological nuclear stress test that shows electrocardiographic ST-segment depression of 1.5 mm and a moderate area of ischemia in the inferior wall. Her only medications are hydrochlorothiazide and simvastatin, and aspirin and metoprolol are added to her medication regimen. Her primary care physician refers her for cardiac catheterization.The approach to this patient raises several important issues given her risk factors, paucity of symptoms, and evidence of what seems to be stable ischemic heart disease with objective evidence of myocardial ischemia. The question of how to approach a patient like this is a highly relevant and important one, as it is unclear whether optimizing medical therapy alone or proceeding to a more definitive diagnostic test and therapy by adding cardiac catheterization and revascularization would lead to a better outcome.It is also important to distinguish our patient from others with CAD for whom …