Case Presentation

• 76 year old man with a history of CAD

• 10 yrs ago presented with anterior MI and not received lytics

• Hypercholesterolemia, Hypertension. Tobacco (20 pack year history)

• Current medications– Aspirin 100 mg qd, Atorvastatin 80 mg qd, Enalapril 10 mg,

Metoprolol ER 95 mg qd

Case Presentation

• Regular angina with moderate exertion. Twice per week.

Rare SL NG use.

– No symptoms of heart failure or volume overload

• Physical Exam:

– BP 105/70 mmHg, HR 62 bpm, RR 18 bpm, BMI 24.8 kg/m2

– Labs: SCr 1.0 mg/dL, A1C: 5.4%

– TC. 202 mg/dl, LDL-C 123, HDL- C 35 mg/dl, Tg 220 mg/dl,

Longitudinal Strain

Nuclear stress test: MPI

Catheterization

Catheterization

• SYNTAX Score 30 pts

• SYNTAX II PCI 33.2 vrs CABG 40.1 – 4 year Mortality PCI 8.8% vrs CABC 15-2%

• EURO SCORE 4 Logistic 2.7

Rule 2 of 3

MVDModerate/Severe

Ischemia

Ventricular Dysfunction

Optimal Medical Therapy Its Not Optimal

Wijeysundera HC, Bennell MC, Qiu F, et al. J Gen Intern Med 2014;29:1031–9.CONFIRM. European Heart Journal (2012) 33, 3088–3097

ER reduced mortality at 2.1

year ER fewer deaths an MI during

4 year follow-up

Extent of ischemia. Benefit from ER?

> 10 % of ischemic had a greater survival

with Revascularization

Hachamovitch R, et al.. Circulation 2003;107:2900–7.COURAGE trial nuclear substudy. Circulation 2008;117:1283–91.

What is the future?• Invasive FFR and NI CFR • ISCHEMIA trial

Stone, G.W. et al. J Am Coll Cardiol. 2016; 67(1):81–99.

Nils P. Johnson,J Am Coll Cardiol 2016;67:2772–88)

Conclusions

• Optimal medical therapy its not optimal

• Revascularization is safe, especially when ischemia is

present.

• SIHD remains unsettled