A 65 year old lady from Canada is visiting her relatives in Florida. She has no health coverage and asks the physician to be least invasive as possible.

On examination during a cardiac catheterization for chest pain, she has single vessel disease affecting the proximal part of the left main coronary artery.   The artery is 85% stenosed.

What is the next best step in the evaluation of the patient?

1. Schedule evaluation of the carotid arteries and consult cardiothoracic surgery for CABG

2. Schedule with the most expert cardiologist for intervention

3. Transfer her to a hospital in Canada where all the treatment will be covered

4. Discharge her and allow her to urgently travel to Canada and get all her work done there as soon as she gets there.

Answer is choice 1.  Left main lesions are the most dangerous lesions. They become more unstable after a cardiac cath. They are not safe for angioplasty as any dissection of the coronary will lead to a sudden deterioration and death.

CARDIOLOGY

Recognize the indications of CABG (coronary artery bypass surgery)

Explanation:

The population that nearly always benefits from CABG does not include everyone with CAD.

The subgroups that benefit are

3 groups of patients-

1) those with triple vessel disease AND LV dysfunction,

2) those with left main disease ,

3) lastly those with Diabetes mellitus as per the BARI trial.

Anyone not falling into these categories is not a great candidate for surgery. If intervention is needed in them, Angioplasty with stent placement is method of choice. Stent placement is followed by Clopidogrel (Plavix) administration for at least 9 months where not contra-indicated.