Do All Critical Lesions Need Stents?
The Benefit of Optimizing Medical Therapy
In certain settings, interventions for critical coronary lesions may not always be the best management of patients. When considering extenuating circumstances such as access to cardiac interventional care, medical management may be more appropriate in patients with stable coronary artery disease (CAD). The case discussed here shows why immediate percutaneous coronary intervention (PCI) is not always necessary, despite the discovery of critical lesions. This discussion will help practitioners make difficult decisions on how to care for patients with critical lesions and stable angina.
A 75-year-old man with no prior history of heart disease presented to his physician because of chest pain that occurred with exertion. He reported that when walking he would experience tightness in his chest, and that the pain would abate when he stopped walking. The patient was then referred to our cardiology clinic for suspected CAD and angina. He underwent a stress test which was found to be positive with ST changes. The patient then underwent cardiac computed tomography (CT) angiography which showed a critical lesion in his left anterior descending (LAD) artery which was severely calcified (Figure 1), confirming the diagnosis of CAD with stable angina.
Figure 1. Patient’s CT angiography showing critical LAD lesion that is heavily calcified.
The patient was then started on optimal medical therapy, including antiplatelet therapy, beta blocker, angiotensin-converting enzyme inhibitor (ACE-I) and a statin. On follow up 90 days later, the patient had no adverse effects of medical therapy and was asymptomatic on exertion when walking 2 km. He was concerned about his critical lesion and sought a second opinion regarding intervention and was told that he would benefit from percutaneous coronary intervention (PCI). e patient came back to us but he was told that considering he was asymptomatic, it was recommended that he not go forth with the intervention, with which he then agreed. Follow up even eight years later showed that this patient has remained asymptomatic, and is fully able to perform his normal activities of daily living.
An estimation of the optimized medical therapy for CAD patients in a specialist MD or primary care MD setting in India is around 28% and 7%, respectively. This leaves considerable room for improvement for pharmacotherapy treatment and lifestyle management interventions of stable angina patients. Further, interventional treatment for patients with stable angina has not been shown to decrease any major cardiovascular events or death over optimized  medical therapy
For our patient, who was being considered for intervention, there are multiple reasons why he and other similar patients are not ideal candidates for intervention. As with many lowincome patients presenting to our clinic, access to large medical centres with advanced interventional capabilities, is limited. This patient lived over an hour away from the nearest large medical centre that would be equipped to address a stent occlusion or other complications of PCI. Such a long distance of travel time could be catastrophic in an emergency. Secondarily, the characteristic of this patient’s critical lesion, which was severely calcified, further requires advanced interventional techniques such as the use of a rotablator, which would have required a more advanced treatment centre than his local hospital.
In asymptomatic patients, coronary artery lesions that appear to be critically stenosed can be more stable than lesions which are less occlusive, owing to revascularization bypassing the lesion and other qualitative features of a lesion. Coronary lesions and plaques can have many features, and the degree of stenosis does not always correlate with the level of ischemia. Statins have been shown to make only modest improvements in lumen calibre, thus owing their benefit to their anti-inflammatory effects on the plaque.
Our patient likely had progressive obstruction at the site of his lesion allowing for revascularization. Considering his swift return to asymptomatic walking when optimized medical therapy was begun, an intervention would have been fraught with potential complications and undue financial burdens on this patient. Many patients would be better served by first optimizing medical therapy for CAD; including antiplatelet therapy, ACE-I, angiotensin receptor blockers (ARBs), a beta blocker and a statin medication at therapeutic doses.
- There is no evidence that PCI reduces death or myocardial infarction (MI) in patients  with stable ischemic heart disease.
- Optimized medical therapy and lifestyle modifications remains significantly low in the population with stable angina and CAD.
- Emphasizing the use of medical therapy and lifestyle modification over PCI in those with stable CAD, even those with critical lesions, is necessary and oen more appropriate for patients who have limited access to medical care.
Ana Karina Jaques, MD, FESC
Goa America Heart Foundation,
Menezes Polyclinic, Althino
Panaji, Goa 403001.
Drexel University College of Medicine
D.A.Neville Mascarenhas, MD, FACC
Clinical Professor of Medicine
Drexel University College of Medicine
Philadelphia, PA, USA
Honorary Cardiologist, Founder Trustee
Goa America Heart Foundation
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