Therapeutic Options for Left Main, Left Main Equivalent, and Three-Vessel Disease

Unusual Presentation of Obstructive Atherosclerotic Coronary Artery Disease With Chronic, Persistent Neck and Shoulder Pain: A Case Report

Ischaemic chest pain or its equivalents are acute-onset in acute coronary syndrome (ACS) and chronic, episodic, and transient in chronic coronary syndrome (CCS). A 56-year-old Caucasian male with a history of premature atherosclerotic coronary artery disease (CAD) presented to secondary care with recurrent presyncope and syncope. He reported a year-long history of persistent left-sided neck and shoulder dull ache/tightness, unrelated to exertion and fluctuating unpredictably. His primary care had diagnosed the pain as musculoskeletal, attributing it to prior physical trauma. However, the pain did not respond to treatment. During his admission for suspected cardiac syncope, he experienced transient chest discomfort, transient inferior ST-segment elevation on electrocardiogram (ECG), and elevated troponin levels, indicating a non-ST-elevation myocardial infarction (NSTEMI). Coronary angiography revealed obstructive atherosclerotic two-vessel disease, with severe proximal stenosis in the right coronary artery (RCA) and moderate-to-severe stenosis in the left anterior descending artery (LAD). His chronic neck and shoulder pain resolved after percutaneous coronary intervention (PCI) with drug-eluting stent (DES) placement in the RCA, confirming it was an anginal equivalent. Although the chronicity of this anginal equivalent may align it more with CCS than ACS, its unremitting nature is inconsistent with CCS. Our patient's history also showed that his ischaemic symptoms changed over time, from remote exertional dyspnoea to persistent neck and shoulder pain, and then to the chest discomfort that preceded his NSTEMI. Our case highlights the importance of heightened clinician awareness of atypical CAD presentations and symptom variability over time. Symptoms initially considered non-anginal should be reassessed for CAD, particularly when alternative treatments prove ineffective. Similar cases like ours, in the future, could prompt updates to CCS diagnostic guidelines to address atypical presentations with persistent pain.

Diagnosis, performance and added value of assessing ventricular dyssynchrony by phase analysis in patients with three-vessel disease: A single-center cross-sectional study in Mexico

BACKGROUND

Three-vessel disease (3VD) is a cardiovascular disorder that affects the three main coronary arteries. Gated myocardial perfusion SPECT (GMPS) evaluates ventricular function, synchrony, and myocardial perfusion. However, the diagnostic performance of GMPS parameters to assess 3VD has not been fully explored.

AIMS

To assess the univariate performance capacity of GMPS parameters, and to evaluate whether phase parameters could provide additional predictive value for the detection of patients with 3VD compared to control subjects.

METHODS

We designed paired retrospective samples of GMPS images of patients with 3VD (stenosis > 70% of left anterior descending, right coronary, and circumflex coronary arteries) and without 3VD. A GMPS in rest-stress protocol was performed using 99mTc-Sestamibi and thallium and analyzed with the 3D method. Area under the receiver-operating characteristic curves (AUROC), decision curve analyses and diagnostic test performance were obtained for univariable analyses and stepwise binomial logistic regression for multivariable performance.

RESULTS

474 Patients were included: 237 with 3VD (84% males, mean age 61.7 ± 9.9 years) and 237 with normal GMPS (51% women, mean age 63.8 ± 10.6 years). The highest AUROC for perfusion parameters were recorded for SSS, SRS and TID. For dyssynchrony parameters, both entropy and bandwidth in rest and stress phases displayed the highest AUROC and diagnostic capacity to detect 3VD. A multivariate model with SRS ≥ 4, SDS ≥ 2, TID > 1.19 and sBW ≥ 48° displayed the highest diagnostic capacity (0.923 [95% CI 0.897-0.923]) to detect 3VD.

CONCLUSION

Perfusion and dyssynchrony were the parameters which were most able to discriminate patients with 3VD from those who did not have CAD.

The Current State of Coronary Revascularization: Percutaneous Coronary Intervention versus Coronary Artery Bypass Graft Surgery

The question of percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) surgery remains among the most important questions in the treatment of coronary artery disease. The leading North American and European societies largely agree on the current guidelines for the revascularization of unprotected left-main disease (ULMD) and multivessel disease (MVD) which are largely supported by the outcomes of several large randomized trials including SYNTAX, PRECOMBAT, NOBLE, and EXCEL. While these trials are of the highest quality, currently available, they suffer several limitations, including the use of bare metal and/or first-generation drug-eluting stents in early trials and lack of updated surgical outcomes data. The objective of this review is to briefly discuss these key early trials, as well as explore contemporary studies, to provide insight on the current state of coronary revascularization. Evidence suggests that in ULMD and MVD, there are similar mortality rates for CABG and PCI but PCI is associated with fewer "early" strokes, whereas CABG is associated with fewer "late" strokes, myocardial infarctions, and lower need for repeat revascularization. Additionally, studies suggest that CABG remains superior to PCI in patients with intermediate/high SYNTAX scores and in MVD with concomitant proximal left anterior descending (pLAD) artery stenosis. Despite the preceding research and its basis for our current guidelines, there remains significant variation in care that has yet to be quantified. Emerging studies evaluating second-generation drug-eluting stents, specific lesion anatomy, and minimally invasive and hybrid approaches to CABG may lend itself to more individualized patient care.