Should a 78-year-old male with a history of CABG, NSTEMI, impaired renal function, and reduced left ventricular function be managed with PCI or OMT?

Management of 78-Year-Old Male with NSTEMI: PCI vs. Medical Management

For this 78-year-old male with a history of CABG, NSTEMI, CKD stage 3, and reduced left ventricular function, percutaneous coronary intervention (PCI) of the distal RCA bifurcation lesion is recommended over medical management alone due to his ongoing symptoms and significant coronary stenosis despite optimal medical therapy.

Patient Assessment and Risk Stratification

This patient presents with several high-risk features:

• Recent NSTEMI with troponin elevation
• Significant distal RCA bifurcation disease (80-90% stenosis)
• Reduced left ventricular function (EF 40-45%)
• CKD stage 3 (creatinine 1.3-1.4)
• Diabetes mellitus
• Prior CABG with patent LIMA to LAD but diseased SVG grafts
• Ongoing anginal symptoms despite optimal medical therapy

Evidence-Based Recommendation

The decision between PCI and continued medical management should be guided by:

1. Symptom Status: The patient has ongoing chest discomfort despite optimal medical therapy, which is nitrate-responsive, indicating active ischemia 1.

2. Coronary Anatomy: The patient has a focal 80-90% stenosis in the distal RCA with involvement of the PDA/PLV bifurcation, which is amenable to PCI 1.

3. Left Ventricular Function: The patient has reduced LV function (EF 40-45%), which places him in a group that may benefit from revascularization 1.

4. Prior CABG Status: The patient has a patent LIMA to LAD but diseased SVG grafts, making him a poor candidate for redo CABG 1.

Specific Guideline Support

According to the ACC/AHA guidelines:

• It is reasonable to perform PCI in patients with UA/NSTEMI and single-vessel or multivessel CAD who are undergoing medical therapy with focal lesions who are poor candidates for reoperative surgery (Class IIa, Level of Evidence: C) 1.

• In patients with ongoing symptoms despite medical therapy and significant coronary stenoses suitable for revascularization, PCI is a preferred approach, particularly when the patient has reduced LV function 1.

• For patients with prior CABG who have focal lesions and are poor candidates for reoperative surgery, PCI is reasonable (Class IIa) 1.

Considerations for This Specific Patient

1. Age and Comorbidities: Despite his advanced age (78 years) and comorbidities (CKD, diabetes), the patient's ongoing symptoms and significant coronary stenosis warrant consideration for PCI 1.

2. Renal Function: With CKD stage 3, there is an increased risk of contrast-induced nephropathy. However, the ACC/AHA guidelines still consider an invasive strategy reasonable in patients with mild to moderate CKD (Class IIa, Level of Evidence: B) 1.

3. Technical Considerations: The distal RCA bifurcation lesion may be technically challenging, but appears amenable to PCI based on the angiographic description.

4. Risk of Redo CABG: Given the patient's age, comorbidities, and prior CABG, the risk of redo CABG would be prohibitively high, making PCI the preferred revascularization option 1.

Procedural Recommendations

If proceeding with PCI:

• Ensure adequate hydration before and after the procedure to minimize risk of contrast-induced nephropathy 2
• Consider staged procedures if multiple vessels require intervention
• Use minimal contrast volume
• Consider radial access to reduce bleeding risk
• Ensure optimal antiplatelet therapy

Potential Pitfalls and Caveats

1. Contrast-Induced Nephropathy: The patient's CKD increases risk of contrast-induced nephropathy. Adequate hydration and minimizing contrast volume are essential 2.

2. Dual Antiplatelet Therapy: The need for prolonged DAPT after PCI must be balanced against bleeding risk in this elderly patient.

3. Bifurcation PCI Complexity: Distal RCA bifurcation lesions can be technically challenging and may require specialized techniques.

4. Restenosis Risk: The patient should be informed about the possibility of restenosis and the potential need for repeat procedures 1.

In conclusion, based on the patient's ongoing symptoms despite optimal medical therapy, significant coronary stenosis amenable to PCI, reduced left ventricular function, and high risk for redo CABG, PCI of the distal RCA bifurcation lesion is recommended over continued medical management alone.