What is the most appropriate next step for a 58-year-old man with worsening chest tightness (angina pectoris) radiating to the left arm, sinus bradycardia on EKG, and an 80% stenosis of the right coronary artery?

Management of Significant Right Coronary Artery Stenosis with Angina

Referral for percutaneous coronary intervention (PCI) is the most appropriate next step for this 58-year-old man with worsening exertional angina, sinus bradycardia, and 80% stenosis of the right coronary artery. 1

Clinical Assessment and Risk Stratification

This patient presents with several high-risk features:

• Worsening chest tightness (angina) with exertion that radiates to the left arm
• Symptoms that resolve with rest (classic stable angina pattern)
• Significant (80%) stenosis of the right coronary artery
• Sinus bradycardia on EKG

The patient meets criteria for high-risk stable ischemic heart disease with:

• Typical angina symptoms
• Significant coronary stenosis (>70%) 1
• Symptoms that are not controlled (worsening despite rest)

Rationale for PCI

1. Symptom Relief: The 2012 ACCF/AHA guidelines clearly state that "CABG or PCI to improve symptoms is beneficial in patients with 1 or more significant (>70% diameter) coronary artery stenoses amenable to revascularization and unacceptable angina despite GDMT" (Class I recommendation, Level of Evidence: A) 1

2. Anatomical Considerations: The patient has single-vessel disease with 80% stenosis of the right coronary artery, which makes PCI the preferred revascularization strategy over CABG 1

3. Bradycardia Considerations: The patient's sinus bradycardia makes increasing beta-blocker dosage (metoprolol) potentially dangerous, as it could worsen the bradycardia and potentially lead to hemodynamic compromise 2

Why Other Options Are Not Appropriate

• Increasing metoprolol to 100mg daily: This could worsen the existing sinus bradycardia and potentially cause hemodynamic instability. The FDA label for metoprolol warns about bradycardia as a significant side effect 2

• Increasing isosorbide mononitrate to 240mg: This would not address the underlying coronary stenosis and could potentially worsen the bradycardia through reflex mechanisms

• Clopidogrel 75mg alone: While clopidogrel would be indicated after PCI, it is not appropriate as standalone therapy for significant coronary stenosis 1

• Referral to electrophysiology: While the patient has bradycardia, the primary issue is the significant coronary stenosis causing angina. Electrophysiology referral would be appropriate if the bradycardia were symptomatic or if the patient required increased beta-blockade that was limited by bradycardia after addressing the coronary stenosis 3

Post-PCI Management

After PCI, the patient should receive:

• Dual antiplatelet therapy with aspirin and clopidogrel 1, 4
• Continued medical therapy for coronary artery disease
• Close follow-up to monitor for restenosis or progression of disease

Potential Pitfalls and Caveats

1. Bradycardia management: If the patient requires higher doses of beta-blockers after PCI but is limited by bradycardia, then electrophysiology consultation for possible pacemaker placement could be considered 3

2. Medication adherence: Ensure the patient understands the critical importance of dual antiplatelet therapy after PCI to prevent stent thrombosis 5

3. Complete assessment: Although PCI of the right coronary artery is the immediate priority, a complete assessment of the patient's coronary anatomy and left ventricular function should be performed during cardiac catheterization to guide long-term management 1

The CAD-RADS classification would categorize this patient as 4A (severe stenosis 70-99% in a single vessel), which typically warrants invasive coronary angiography with intent for revascularization, particularly with the patient's symptomatic presentation 1.