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Chapter 44: Coronary Artery Bypass Grafting and Percutaneous Interventions in Stable Ischemic Heart Disease

Which of the following findings on noninvasive testing should prompt referral of a patient for coronary angiography?

A. Exercise treadmill, > 2 mm of ST depression

B. Failure to increase systolic pressure to > 120 mm Hg or a sustained decrease of > 10 mm Hg during exercise

C. Resting perfusion abnormalities > 10% of the myocardium

D. Stress-induced left ventricular dilatation

E. All of the above

The answer is E. (Hurst’s The Heart, 14th Edition, Chap. 44) Patients referred for diagnostic noninvasive stress testing should be considered for coronary angiography in the presence of high-risk findings. A number of such factors are suggested (Table 44-1; options A through D are incorrect).

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Table 44-1. Criteria for Referring Patients to Coronary Angiography

Exercise Treadmill

 Exercise treadmill, > 2 mm of ST depression;

 Exercise-induced ST-segment elevation;

 Exercise-induced ventricular tachycardia/ventricular fibrillation; and

 Failure to increase systolic pressure to > 120 mm Hg or a sustained decrease of > 10 mm Hg during exercise

Myocardial Perfusion Imaging

 Severe left ventricular dysfunction, not readily explained;

 Resting perfusion abnormalities > 10% of the myocardium;

 Severe stress-induced left ventricular dysfunction;

 Stress-induced perfusion abnormalities involving > 10% of the myocardium or stress and mental scores indicating multiple territories at risk;

 Stress-induced left ventricular dilatation; and

 Increased lung uptake.

Stress Echocardiography

 Inducible wall motion abnormalities involving > 2 segments or 2 coronary beds

Coronary Computed Tomography

 Multivessel obstructive coronary disease or left main stenosis

Modified with permission from Mancini GB, Gosselin G, Chow B, et al. Canadian Cardiovascular Society. Canadian Cardiovascular Society guidelines for the diagnosis and management of stable ischemic heart disease, Can J Cardiol. 2014 Aug;30(8):837-849.

A 55-year-old man with hypertension, dyslipidemia, and type II diabetes mellitus treated with subcutaneous insulin undergoes coronary angiography following a high-risk stress test with hypotensive blood pressure response. He is found to have proximal left anterior descending coronary artery (LAD) stenosis of 85%, as well as a 70% lesion in the mid-right coronary artery.

Which of the factors in this patient’s history would favor referral for surgical revascularization?

A. A history of diabetes

B. The presence of two or more preexisting risk factors

C. Young age

D. SYNTAX score of 20

E. None of the above

The answer is A. (Hurst’s The Heart, 14th Edition, Chap. 44) Patients ...

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