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.
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.
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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