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Clinical Crossroads | Clinician's Corner

A 69-Year-Old Woman With Left Main Coronary Artery Disease

Joseph P. Carrozza, MD, Discussant; Frank W. Sellke, MD, Discussant
JAMA. 2004;292(20):2506-2514. doi:10.1001/jama.292.20.2506.
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DR DELBANCO: Mrs D is a 69-year-old woman with angina pectoris and left main coronary artery disease, documented recently by cardiac catheterization. Retired from a career in business, she volunteers in charitable organizations. Mrs D is married and is close to her children and grandchildren. She lives in a suburb of Boston and has Medicare and supplemental health insurance.

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Figure 1. Angiograms and Diagram of Left Main Coronary Artery Before and After Stent Placement
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A, A high-grade stenosis is present at the aorto-ostial junction of the left main coronary artery (white arrowhead). B, Following placement of a bare metal stent coated with heparin, there is minimal residual stenosis (top). Diagram of left main coronary artery with stent (bottom). C, Angiographic follow-up at 3 months shows minimal in-stent restenosis.

Figure 2. Algorithm for CABG vs Stent Placement in Left Main Coronary Artery Disease
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Unlike coronary artery bypass grafting (CABG) for left main coronary disease, stenting for left main coronary disease has not been evaluated in randomized or long term trials. Therefore, stenting should be considered only in situations in which CABG would carry a high risk of surgical morbidity or mortality. Patients should understand that stent placement should be followed by surveillance angiography. Drug eluting stents are always preferred over bare metal stents but currently are available only for vessel diameters between 2.5 and 4.75 mm. Stent placement is more difficult for ostial lesions and in cases in which the left anterior descending or left circumflex arteries also have lesions. Because of the high likelihood of adverse outcomes, medical management should be reserved for patients for whom revascularization is not an option. In addition to the interventions listed, patients should reduce their cardiovascular risk factors through diet, exercise, blood pressure control, lipid lowering, and other preventive measures.

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