What is the recommended treatment for a patient with suspected coronary artery disease (CAD), reversible defect on Technetium (99mTc) Sestamibi study, elevated TID ratio, calcified coronary arteries, normal myocardial thickening and wall motion, and LVEF of 64%?

Management of Reversible Ischemia with Elevated TID and Preserved LVEF

This patient requires invasive coronary angiography with FFR/iFR assessment to guide revascularization decisions, given the documented reversible ischemia, elevated TID ratio suggesting multivessel disease, and calcified coronary arteries, despite preserved ventricular function. 1

Immediate Diagnostic Pathway

Proceed directly to invasive coronary angiography (ICA) with physiological assessment capability. The combination of reversible ischemia on SPECT, elevated TID ratio (1.24, suggesting multivessel CAD), and coronary calcification on non-contrast CT constitutes high-risk features that warrant invasive evaluation. 1

• The 2024 ESC guidelines give a Class I, Level C recommendation for ICA (with FFR/iFR when necessary) in patients with severe CAD, particularly when symptoms are refractory to medical treatment or when high-risk clinical profiles are present 1
• The elevated TID ratio >1.19 is a marker of severe and extensive CAD, often indicating left main or three-vessel disease, which significantly alters management 1
• Normal wall motion and preserved LVEF (64%) do NOT exclude the need for revascularization when reversible ischemia is documented 1

Physiological Assessment During Catheterization

FFR or iFR measurement is mandatory during catheterization to determine hemodynamic significance of stenoses, especially given the calcified nature of the arteries which can complicate visual assessment. 1

• FFR ≤0.80 indicates hemodynamically significant stenosis requiring revascularization consideration 1
• FFR >0.80 allows safe medical management without increased risk of death, MI, or delayed target-vessel revascularization 1
• Calcified stenoses (as indicated by non-contrast CT findings) are often circumferential and heavily calcified, making visual angiographic assessment unreliable 1

Revascularization Decision Algorithm

The revascularization strategy depends on angiographic findings:

If Left Main ≥50% or Three-Vessel Disease ≥70% (CAD-RADS 4B):

• Proceed with revascularization (PCI or CABG depending on anatomy and SYNTAX score) 1
• This represents the highest-risk anatomy requiring intervention regardless of symptom severity 1

If Single or Two-Vessel Disease 70-99% (CAD-RADS 4A):

• Revascularization is indicated if:
  • FFR ≤0.80 in the territory of reversible ischemia 1
  • Very high-grade stenosis >90% 1
  • Persistent symptoms despite optimal medical therapy 1
• The documented reversible defect on SPECT already confirms ischemia, supporting revascularization in this context 1

If Moderate Stenosis 50-69% (CAD-RADS 3):

• FFR/iFR assessment is essential to determine if the moderate stenosis is causing the documented ischemia 1
• Revascularize only if FFR ≤0.80 1

Concurrent Medical Therapy (Initiated Immediately)

Regardless of revascularization decisions, optimize guideline-directed medical therapy:

Antiplatelet Therapy:

• Aspirin 75-100 mg daily (lifelong unless contraindicated) 1
• If revascularization performed, dual antiplatelet therapy (aspirin + P2Y12 inhibitor) per standard post-PCI/CABG protocols 1

Anti-Ischemic Medications:

• Beta-blocker as first-line (e.g., metoprolol, carvedilol) 1, 2
• Add calcium channel blocker (e.g., amlodipine 5-10 mg daily) if beta-blocker insufficient or contraindicated 3, 2
• Sublingual nitroglycerin for acute symptom relief 1, 2
• Consider ranolazine as second-line adjunctive therapy if symptoms persist 2

Lipid Management:

• High-intensity statin therapy (atorvastatin 40-80 mg or rosuvastatin 20-40 mg) targeting LDL <70 mg/dL, ideally <55 mg/dL 1, 2
• All patients with documented CAD require statin therapy regardless of baseline lipid levels 1, 2

Risk Factor Modification:

• Blood pressure control to <130/80 mmHg with ACE inhibitor or ARB preferred 1
• Diabetes management if present (HbA1c <7%) 1
• Tobacco cessation (mandatory) 1, 2
• Structured exercise program and weight management 1, 2

Critical Pitfalls to Avoid

Do not rely solely on preserved LVEF to defer invasive evaluation. Normal ventricular function does not exclude high-risk CAD requiring revascularization. 1, 4

Do not dismiss the elevated TID ratio. TID >1.19 is a powerful marker of severe, extensive CAD and should prompt aggressive evaluation even when regional defects appear limited. 1

Do not perform repeat non-invasive testing. The patient already has documented reversible ischemia and high-risk features; additional stress testing delays definitive management. 1

Do not attribute findings to attenuation artifact alone. While inferior attenuation was noted, the anteroseptal defect is reversible and less likely artifactual, especially with elevated TID and coronary calcification. 5, 6

Do not defer revascularization based on "stable" symptoms alone. The presence of documented ischemia with high-risk features (elevated TID, calcified arteries) indicates increased risk of adverse events regardless of current symptom burden. 1

Follow-Up Strategy Post-Intervention

• Periodic cardiovascular assessment (at minimum annually) to evaluate risk factor control, medication adherence, and symptom status 1
• Repeat risk stratification with stress imaging only if new or worsening symptoms develop 1
• Coronary CTA is NOT recommended for routine follow-up in patients with established CAD 1