Author + information
- Spencer B. King III, MD, Editor-in-Chief, JACC: Cardiovascular Interventions⁎ ()
- ↵⁎Address for correspondence to:
Spencer B. King III, MD, Editor-in-Chief, JACC: Cardiovascular Interventions, Saint Joseph's Heart and Vascular Institute, 5665 Peachtree Dunwoody Road, NE, Atlanta, Georgia 30342
Guidelines are valuable tools to inform our decisions. The focused update ST-segment elevation myocardial infarction and percutaneous coronary intervention guidelines was just published last month, and the experience of all those working on the project was highly rewarding. As we become more evidence-based in our diagnostic and therapeutic decisions, the development of guidelines and their constant revision will be necessary. I am a staunch defender of the guidelines process as it enables the collection of the available evidence, and by doing so, provides an informed background for decision making. However, I had a recent experience that points to how important judgment is in dealing with disparate evidence and guidelines recommendations. A colleague of mine, who is a cardiovascular physician in his late 50s, considered himself the image of good health. In order to be a collaborator in clinical research, he volunteered for a lung cancer screening study using chest computed tomography. The lungs were fine, but the left anterior descending coronary artery was reported as showing heavy calcification in the proximal portion. He was shocked because he is thin, he exercises regularly, and has had low- and high-density lipoprotein values that would be the envy of Dr. Mehmet Oz. Nonetheless, because of a positive family history and the unexpected calcification, he underwent exercise stress testing. The Bruce test was stopped at stage 2 because his heart rate was 160 beats/min and he developed a 3-mm ST-segment depression in the anterior leads. The nuclear component of the test (he is a physician, after all) was read as showing no ischemia.
This physician came to see me because coronary arteriography had been recommended and he wanted additional advice.
I told him, “You probably have heavy calcification in the artery wall but have no obstructive disease. If they decide to cath you, insist on having a fractional flow reserve before letting anyone place a stent because the calcification is probably not indicative of a flow-limiting lesion.”
He asked, “Could it be a left main with balanced ischemia?” (Sounds like a board question, doesn't it?)
Since he was asymptomatic with no ischemia seen on perfusion scanning, should catheterization be considered? What about the ST-segment depression at an early stage? I said, “Surely there is something wrong because you exercise 3 days a week for 30 minutes on the elliptical machine without symptoms.”
“Absolutely none,” he replied.
Should the recommendation be to take anti-ischemia medication in addition to antiatherosclerotic drugs and avoid catheterization unless symptoms intervene? What should be the advice about his exercise program? Should he limit his activity to stage 2 type exercise despite his desire to continue working out? Should he have repeat perfusion scans, and if so, how often? His syndrome could be defined in no way other than stable ischemic heart disease, if he truly had ischemia as suggested by the electrocardiogram but denied by the nuclear scan. Surely he could live comfortably with the knowledge that without an acute syndrome and with a normal perfusion scan, his risks would not be classified as high. Not! This cardiovascular-trained physician was a basket case and planned to remain so unless he could be convinced that he had no obstruction, and then he would pursue preventive therapy in earnest.
A coronary arteriogram was performed and showed an angiographic diameter stenosis of 70% in the proximal anterior descending coronary. The FFR was not done (nobody follows my advice) but intravascular ultrasound was and the minimal area of the vessel was 2.4 mm2. A drug-eluting stent was expertly placed on a Friday and the patient was back performing surgical procedures by Monday. He is having a number of advanced lipid tests and genetic studies to see if he has inherited an atherosclerotic trait from his mother, who had stenting in her early 60s. Now he feels fine and seems to have more energy and can climb stairs with less heavy breathing. He had not recognized a previous exercise limitation.
Is there a guideline for this specific situation? Not exactly. Was his life saved? Probably not. Is he better off? Undoubtedly. Is knowledge of the guidelines important in making these judgments? Definitely. Guidelines and appropriateness criteria are great guides. That is what they are—great guides.