MKSAP Quiz: optimal management of coronary artery disease
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A 58-year-old woman with known coronary artery disease presents for a general evaluation. She had coronary angiography and a percutaneous intervention with dilation and stenting of a mid-right coronary artery lesion 1 year ago. At that time, a 70% lesion on the distal left anterior descending artery was observed. Left ventricular function at that time was normal, and a stress imaging study performed 6 months after the intervention demonstrated no ischemia. The patient experiences rare episodes of chest discomfort, which occur with marked activity and are promptly relieved by rest. She has nitroglycerin available but has not needed to use it for many months. Her cardiovascular risk factors include hyperlipidemia, prior tobacco use, a family history of coronary artery disease, and a history of hypertension. Current medications include atenolol, 50 mg daily, atorvastatin, 40 mg daily, ramipril, 10 mg daily, aspirin, 81 mg daily, and sublingual nitroglycerin as needed.
Physical examination shows a heart rate of 80/min and a blood pressure of 140/80 mm Hg bilaterally. The cardiac examination is normal. The jugular venous pressure and carotid and peripheral vascular examinations are unremarkable. The LDL cholesterol is 68 mg/dL (1.76 mmol/L) and creatinine and hemoglobin concentrations are normal.
What is the optimal management for this patient?
A. Add a calcium-channel blocker
B. Increase the angiotensin-converting enzyme inhibitor
C. Increase the β-blocker
D. Add a long-acting nitrate
E. Increase the atorvastatin
MKSAP Answer and Critique
The correct answer is C) Increase the β-blocker. This item is available online to MKSAP 14 subscribers in the Cardiovascular Medicine section, Item 120.
The patient has chronic stable angina. The initial step for improving symptom control is medication adjustment. Prehypertension is noted on examination in this patient and improved blood pressure control with a target less than 130/85 mm Hg would be advisable. In addition, the resting heart rate would suggest that she is not receiving adequate β-blocker therapy (goal for resting heart rate, 55-60/min); an increased dosage of atenolol would be appropriate for this patient.
Long-acting nitrates and calcium-channel blockers are indicated for patients with chronic coronary artery disease and could be considered if the increase in β-blocker does not improve blood pressure control. The patient is on an adequate dose of angiotensin-converting enzyme inhibitor (ramipril) and increasing this is unlikely to improve her angina. Her LDL cholesterol is less than 70 mg/dL (<1.81 mmol/L), which meets current guidelines, thus an increase in atorvastatin is not required at this time.
Key Point
- Medical therapy is the basis for treatment of patients with chronic stable angina.Medical therapy in patients with stable angina is directed toward the restoration of the supply/demand balance of myocardial oxygen and the prevention of platelet aggregation.