Management of Stable Coronary Disease...

NEJM之前有一個在網路投票..不是選什麼美少女或是啥的..網路資源總被利用來幹這些事情..是投票表決一個有爭議的案例.. 投票的案例是這樣的: A 65-year-old man with hypertension , obesity , and type 2 diabe...



A 65-year-old man with hypertension, obesity, and type 2 diabetes mellitus has been under your care for the past 5 years. He has been receiving hydrochlorothiazide (25 mg daily) and metformin (500 mg twice daily); his blood pressure is 130/82 mm Hg, his body-mass index is 32, and his glycated hemoglobin is 7.5%.

He comes to your office seeking advice about the management of his recently diagnosed coronary artery disease. Two weeks earlier, he had presented with chest tightness and shortness of breath after walking two blocks. His symptoms resolved within a few minutes at rest. An exercise-tolerance test on a treadmill was performed according to the Bruce protocol, along with myocardial perfusion imaging. The patient exercised for 8 minutes, stopping because of chest pressure and dyspnea; his peak systolic blood pressure was 160 mm Hg, and his peak heart rate was 140 beats per minute. Electrocardiography showed ST-segment depression of 1 mm in the anterolateral leads. The perfusion study revealed a fixed perfusion defect of moderate size in the anterior wall and a reversible defect of moderate size in the anterolateral wall.

The patient underwent cardiac catheterization and was found to have multivessel coronary artery disease, with

- Occlusion
of the first diagonal branch of the LAD coronary artery
- A long lesion with 70% stenosis in the midportion
of the LAD coronary artery
- 80% stenosis
with a calcified lesion in the proximal LCX coronary artery
- 50% stenosis of the posterior descending coronary

A left ventriculogram obtained during the procedure
showed anterior-wall hypokinesis and a left ventricular ejection fraction of 45%. The patient was advised to discuss management of his coronary artery disease with you before making a decision about how to proceed; you have received the results of his exercise test and his catheterization report.

這樣的病患該怎麼治療呢? 在投票中舉出了三種策略..

(1) 內科藥物治療: 包括aspirin, ACEIs, beta-blockers, nitrates與更加嚴格的血糖控制
(2) 內科藥物治療加上PCI
(3) 內科藥物治療加上CABG



是你會選擇哪種治療呢? 待續..

Adapted from N Engl J Med. 2007; 357: 1762-6.

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