What is the next step in managing a 75-year-old male with continued shortness of breath after percutaneous coronary intervention (PCI) to the right coronary artery (RCA) and rotational atherectomy to the mid RCA, despite improvement in exertional dyspnea and initiation of Lasix (furosemide) for pulmonary edema?

From the Guidelines

For this 75-year-old male with persistent shortness of breath after PCI, I recommend a comprehensive approach including optimization of his current Lasix therapy and a thorough cardiac and pulmonary evaluation. First, assess the effectiveness of the current Lasix dose by monitoring symptom improvement, daily weights, and fluid status. Consider increasing the dose if needed based on response and renal function, as suggested by the patient's initial response to Lasix therapy 1. Next, obtain a chest X-ray to evaluate for persistent pulmonary edema or other pulmonary pathology. An echocardiogram would be valuable to assess left ventricular function, valvular disease, and potential diastolic dysfunction. BNP levels should be checked to help differentiate cardiac versus non-cardiac causes of dyspnea. Additionally, pulmonary function tests may be warranted to rule out concurrent pulmonary disease, especially given his smoking history. Ensure optimal management of his underlying conditions including hypertension, hyperlipidemia, and coronary artery disease. Consider adding or optimizing other heart failure medications such as ACE inhibitors or beta-blockers if indicated by cardiac function assessment, as recommended by the 2021 ACC/AHA/SCAI guideline for coronary artery revascularization 1. The persistent shortness of breath despite successful PCI suggests either incomplete revascularization, diastolic dysfunction, or potentially non-cardiac causes that require further investigation to guide appropriate therapy. It is also important to consider the potential for pulmonary embolism as a cause of shortness of breath, as suggested by the case report of a patient with paradoxical embolization and simultaneous pulmonary embolization 1. However, the most recent and highest quality study, the 2021 ACC/AHA/SCAI guideline, does not provide specific recommendations for the evaluation of pulmonary embolism in this context 1. Therefore, the focus should be on optimizing the patient's cardiac and pulmonary status, and further evaluation and management should be guided by the patient's response to therapy and the results of diagnostic testing. The use of a radial artery as a surgical revascularization conduit is preferred versus the use of a saphenous vein conduit to bypass the second most important target vessel with significant stenosis after the left anterior descending coronary artery, as recommended by the 2021 ACC/AHA/SCAI guideline 1. However, this is not directly relevant to the patient's current presentation and should not influence the immediate management of his shortness of breath. The patient's history of coronary artery disease and previous PCI suggests that he is at high risk for further cardiac events, and therefore, optimal management of his underlying conditions is crucial to reduce his risk of morbidity and mortality, as emphasized by the ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Edema Therapy should be individualized according to patient response to gain maximal therapeutic response and to determine the minimal dose needed to maintain that response. The dose may be raised by 20 or 40 mg and given not sooner than 6 to 8 hours after the previous dose until the desired diuretic effect has been obtained. Geriatric patients In general, dose selection for the elderly patient should be cautious, usually starting at the low end of the dosing range

The patient is already on Lasix (furosemide) for fluid in his lungs. For his continued shortness of breath, the dose of furosemide may be titrated up by 20 or 40 mg, given not sooner than 6 to 8 hours after the previous dose, until the desired diuretic effect has been obtained, while being cautious due to the patient's geriatric status 2.

From the Research

Patient Follow-up after PCI Placement

The patient is a 75-year-old male with a history of hypertension, hyperlipidemia, and coronary artery disease, who underwent PCI placement with rotational atherectomy to the mid RCA. He reports an improvement in exertional shortness of breath but still experiences some shortness of breath and has been started on Lasix for fluid in his lungs.

Possible Causes of Shortness of Breath

• The patient's shortness of breath could be due to various factors, including residual ischemia, heart failure, or other cardiac conditions 3.
• The study by 4 found that predictors of decreased left ventricular function after PCI include LV dysfunction at index admission, renal insufficiency, and peak creatine kinase.
• Another study by 5 found that PCI can improve left ventricular ejection fraction and diastolic function in patients with coronary artery disease.

Next Steps in Management

• Further evaluation of the patient's left ventricular function and ischemia burden may be necessary to determine the cause of his shortness of breath 6.
• The patient's treatment plan should be optimized, including medication management and possible further intervention, such as coronary artery bypass grafting (CABG) or additional PCI 7.
• A multidisciplinary approach, including input from cardiologists, cardiac surgeons, and other specialists, may be necessary to determine the best course of action for the patient 6.