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PATIENT CASE

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A 75-year-old woman was referred to cardiology for evaluation for dizziness. She complains of intermittent dizziness for a year not related to position change, as well as progressive dyspnea on exertion when she walks 50 feet. If she persists, she develops throat and bilateral arm discomfort that quickly resolves with rest. Symptoms have progressed over the past 3 months, with decreased exercise capacity.

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A comprehensive evaluation for her dizziness included evaluation of her cerebrovascular anatomy, which showed antegrade vertebral artery flow bilaterally without stenosis and mild left internal and severe right internal carotid stenosis. She has no stroke-like symptoms.

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Her past medical history includes hypertension, hypercholesterolemia, severe pulmonary fibrosis requiring home oxygen, and peripheral arterial disease treated with bilateral lower extremity percutaneous intervention.

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Current medications include amlodipine, benazepril, aspirin, atorvastatin, omeprazole, prednisone, and albuterol inhaler. She has no known drug allergies.

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She is a former insurance agent who does not consume alcohol or use recreational drugs. She smoked 2 packs of cigarettes a day for 25 years and quit 20 years ago.

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Her mother died of a myocardial infarction at age 63. Her father died of natural causes in his 80s.

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Electrocardiography showed normal sinus rhythm with left atrial enlargement. A transthoracic echocardiogram showed preserved left ventricular systolic function with an estimated ejection fraction of 60% to 65%, mild concentric left ventricular hypertrophy, and moderate left atrial enlargement. No significant valvular heart disease was noted.

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MANAGEMENT

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Since the pretest probability of obstructive coronary artery disease (CAD) was high, coronary angiography was performed. The left main coronary artery had a severely calcified stenosis that was treated with rotational atherectomy and provisional drug-eluting stent placement into the proximal left anterior descending artery (Figures 14-1, 14-2, 14-3, 14-4). Orbital atherectomy is an alternative option to facilitate stent delivery (Figures 14-5 and 14-6).

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Figure 14-1

Moderate coronary calcification on intravascular ultrasound. Note the bright echodensity subtending a nearly 180° arc involving the intima.

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Figure 14-2

Focal calcified stenosis of the distal left main coronary artery (arrow).

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Figure 14-3

Lack of opacification of the distal left main coronary artery, consistent with a severe focal calcified stenosis.

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Figure 14-4

Rotational atherectomy device proximal to the stenotic segment.

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Figure 14-6

Orbital atherectomy device advancing across a calcified proximal circumflex stenosis.

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