Case presentation

A remarkably healthy and independent 89-year-old woman, with a prior history of hypertension and carotid atherosclerosis treated with lisinopril, hydrochlorothiazide, and aspirin, reported a 6-month history of progressive fatigue and dyspnea. Previously able to regularly walk several miles at a time, her symptoms caused a marked restriction in her exercise capacity and, at the time of presentation, she was no longer able to walk more than a block without having to stop to rest. Additionally, over the preceding 3 weeks, she developed chest tightness with minimal exertion. This symptom prompted her to seek medical attention. Her physician scheduled a stress test but she developed rest chest pain along with severe dyspnea and diaphoresis before this test could be performed and was admitted to the hospital.

Upon presentation in the emergency department, she was symptom-free and a 12-lead electrocardiogram showed Q waves inferiorly without acute ischemic changes. Serum cardiac biomarkers were not elevated. Her physical examination was notable for systolic hypertension with a blood pressure of 214/77 mmHg in both arms, a heart rate of 73 beats per minute, bilateral carotid bruits, and a systolic murmur of aortic sclerosis. The routine admission laboratory studies were normal, including renal function.

Given her advanced age, negative cardiac isoenzymes, and marked systolic hypertension on presentation without a trial of adequate medical therapy, a beta-blocker, statin, and long-acting nitrates were added to her medical regimen. A pharmacologic stress perfusion scan was performed the next day. During the test she developed severe chest pain associated with diffuse ST-segment depression and reversible ischemia in the anterior wall. The patient agreed to undergo catheterization.

Cardiac catheterization

Coronary angiography revealed multivessel coronary disease with severe disease in the proximal segment of the right coronary artery and severe disease of the midportion of the left anterior descending coronary artery (Figures 23-1, 23-2 and Video 23-1). The operator judged the right coronary artery suitable for percutaneous coronary intervention; however, the left anterior descending artery provided several challenges. Not only did the vessel appear small in caliber, there was also marked tortuosity with diffuse disease surrounding the severely stenosed segment. Prior to the catheterization, the patient dismissed the option of bypass surgery and agreed only to percutaneous revascularization. The patient confirmed this after she was presented with the catheterization results, and the operator proceeded with a multivessel intervention on the right coronary artery and left anterior descending artery.

FIGURE 23-1 This is a left anterior oblique coronary angiogram of the right coronary artery, showing a severe stenosis in the proximal segment (arrow).

FIGURE 23-2 This angiogram of the left coronary artery in a right anterior oblique projection with cranial angulation depicts the severe stenosis in the midportion of the artery (arrow

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