Coronary angiogram - TM

Cardiologist's Note: Coronary angiogram - TM Clinical presentation: The patient, a 62-year-old male, presented with exertional chest pain consistent with unstable angina, ongoing for the past two weeks. He reported no recent hospital admissions. Relevant medical history includes hypertension and dyslipidaemia. Initial laboratory findings revealed an elevated troponin I level of 0.8 ng/mL. An echocardiogram performed prior to catheterisation showed normal left ventricular ejection fraction of 58% with no significant regional wall motion abnormalities. CORONARY ANGIOGRAPHY FINDINGS Left main coronary artery: The left main coronary artery was patent with no evidence of significant stenosis or plaque formation. It bifurcated into the left anterior descending and left circumflex arteries without notable abnormalities. Left anterior descending artery: The proximal left anterior descending artery showed a focal, severe stenosis of approximately 90% with evidence of soft plaque. The mid and distal segments were free of significant disease. Multiple diagonal branches originated normally and were free of significant disease. Left Circumflex artery: The left circumflex artery was patent throughout its course, with mild non-obstructive plaque noted in the proximal segment. The obtuse marginal branches were normal in appearance. Right coronary artery: The right coronary artery was found to be dominant, arising normally from the right aortic sinus. It demonstrated mild diffuse atherosclerosis, but no flow-limiting lesions were identified in its proximal, mid, or distal segments. Pressure Wire Study A pressure wire study was undertaken in the left anterior descending artery to assess the haemodynamic significance of the observed stenosis. Hyperaemia was induced using intravenous adenosine at a rate of 140 mcg/kg/min, which resulted in the characteristic hyperaemic response. The patient reported mild chest discomfort during hyperaemia, consistent with his presenting symptoms. Result: The resting Pd/Pa was 0.92. The Peak FFR was measured at 0.71, confirming the haemodynamic significance of the severe stenosis in the proximal left anterior descending artery. PERCUTANEOUS INTERVENTION to the LAD / RCA / LCX Percutaneous coronary intervention was performed on the proximal left anterior descending artery. A 6F EBU 3.5 guide catheter was utilised. A Runthrough NS guidewire was advanced across the lesion. Predilation was performed with a 2.5 x 15 mm Sprinter NC balloon at 14 atm for 20 seconds. A Resolute Onyx Drug Eluting Stent, 3.0 x 24 mm, was deployed at the site of the stenosis at 16 atm for 25 seconds, resulting in optimal angiographic outcome with TIMI 3 flow. Post-dilation was performed with a 3.0 x 12 mm NC Euphora balloon at 18 atm for 15 seconds to ensure full stent apposition and expansion. CONCLUSION and RECOMMENDATIONS 1. The procedure was uneventful and successfully comprised a coronary angiogram and percutaneous coronary intervention with drug-eluting stent implantation in the left anterior descending artery. 2. Pharmacotherapy recommendations include dual antiplatelet therapy (DAPT) with Clopidogrel 75mg daily for 12 months, in addition to lifelong Aspirin 75mg daily. The patient will continue with high-intensity statin therapy (atorvastatin 80mg daily) and Ezetimibe 10mg daily to lower vascular risk. 3. Ongoing medical and foundational lifestyle modifications are crucial to reduce the risk of metabolic syndrome and vascular sequelae. Specific aims include reducing insulin resistance through dietary changes, improving blood pressure control, reducing visceral adiposity, maintaining an ideal waist circumference of <102cm for males, and reducing triglycerides to <1.7 mmol/L and LDL cholesterol fraction to <1.4 mmol/L. 4. The patient is scheduled for a follow-up visit with the cardiology clinic in 6 weeks on 1 November 2024.