A 55-year-old man with type 2 diabetes mellitus and hypertension comes to the physician with exertional chest pain over the last 3 months that has worsened recently. He reports chest pain, occasionally accompanied by diaphoresis, after walking one block. His medications include low-dose aspirin, metoprolol, rosuvastatin, insulin detemir, and nitroglycerin as needed. Cardiac catheterization shows proximal left anterior descending artery stenosis of 90%, right coronary artery stenosis of 85%, and left circumflex artery stenosis of 75%. His left ventricular ejection fraction is 45%. His hemoglobin A1C is 7.8% and LDL cholesterol is 110 mg/dL. What is the most appropriate management for this patient?

Question

A 55-year-old man with type 2 diabetes mellitus and hypertension comes to the physician with exertional chest pain over the last 3 months that has worsened recently.  He reports chest pain, occasionally accompanied by diaphoresis, after walking one block.  His medications include low-dose aspirin, metoprolol, rosuvastatin, insulin detemir, and nitroglycerin as needed.  Cardiac catheterization shows proximal left anterior descending artery stenosis of 90%, right coronary artery stenosis of 85%, and left circumflex artery stenosis of 75%.  His left ventricular ejection fraction is 45%.  His hemoglobin A1C is 7.8% and LDL cholesterol is 110 mg/dL.  What is the most appropriate management for this patient?

Quizplus · Accepted Answer

Explanation: This patient has crescendo angina pectoris, severe multivessel coronary artery disease (CAD) with involvement the proximal left anterior descending artery (LAD), and left ventricular systolic dysfunction. The goals of treatment in patients with CAD are to improve symptoms, reduce cardiovascular morbidity, and improve overall survival. This is achieved using a comprehensive approach, with aggressive lifestyle modifications, optimal medical therapy, and coronary revascularization in appropriately selected patients. Coronary revascularization is indicated primarily for 2 groups of patients with stable angina: Patients with refractory angina despite maximal medical therapy Patients in whom revascularization will improve long-term survival. This includes those with left main coronary stenosis and those with multivessel CAD (especially involving the proximal LAD) along with left ventricular systolic dysfunction. Clinical trials have shown that for patients with diabetes and multivessel CAD, coronary artery bypass graft (CABG) surgery is superior to percutaneous coronary intervention (PCI) with drug-eluting stents because of a lower rate of all-cause mortality and myocardial infarction with CABG. CABG in this population is also associated with lower rates of repeat revascularization than PCI. (Choice B) All patients with CAD, with or without coronary revascularization, should be treated with aggressive risk factor modification. This includes lifestyle and dietary changes to improve glycemic control, smoking cessation, and appropriate medical therapy with low-dose aspirin and adequate treatment for hypertension and hyperlipidemia. Ranolazine, an antianginal agent, is effective in reducing the frequency or severity of anginal symptoms in patients with refractory symptoms on conventional medical therapy with nitrates, beta blockers, and/or calcium channel blockers. It has not been shown to improve long-term survival in patients with CAD. It is also not recommended in patients with multivessel CAD that is amenable to percutaneous or surgical revascularization. (Choice C) Amlodipine is an effective antihypertensive agent in patients with CAD. Niacin is also occasionally used in patients with dyslipidemia with low HDL levels. However, there is no evidence that these agents improve long-term clinical outcomes in those with CAD. (Choices D and E) PCI with bare metal or drug-eluting stents is an excellent revascularization option for patients with refractory angina due to severe single- or two-vessel CAD not involving the proximal LAD. However, CABG is superior to PCI in patients with multivessel CAD (especially involving the proximal LAD) and left ventricular dysfunction, with lower rates of repeat revascularization and improved clinical outcomes. Educational objective: In patients with diabetes and multivessel coronary artery disease, coronary artery bypass graft (CABG) surgery is preferred over percutaneous coronary intervention due to a lower rate of all-cause mortality and myocardial infarction with CABG. References: Strategies for multivessel revascularization in patients with diabetes. (http://www.ncbi.nlm.nih.gov/pubmed/23121323) 2011 ACCF/AHA guideline for coronary artery bypass graft surgery: a report of American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. (http://www.ncbi.nlm.nih.gov/pubmed/22064600)

A 55-Year-Old Man with Type 2 Diabetes Mellitus and Hypertension