Three-vessel coronary artery disease treatment in an elderly patient

Abstract

Background. Coronary artery disease is the leading cause of mortality and morbidity in elderly patients (≥65years old). This population, usually, have a more extensive and complex coronary disease as well as more associated comorbidities and frailty. Revascularization (by either PCI or CABG aiming complete revascularization) is the treatment of choice. Case report. A 65 years old, female, presented in the emergency department complaining of: shortness of breath at minimal exertion, episodes lasting for 5-20 min relieving at rest, fatigue and palpitations. History: Hypertension for ≥15years, max. BP 220/120mmHg, diabetes mellitus type 2 for 7 years, chronic atrial fibrillation for 3 years, ischemic stroke (2016), no permanent medication except metformin 850mg twice daily. Objective: mild ankle swelling, cracking rales in the lower lung fields on auscultation. HR – 98 bpm, BP - 185/95 mmHg, SaO2 – 94%. Laboratory testing: troponin I – 0.58ng/ml, NT-proBNP – 3241pg/ml. ECG: rhythm – atrial fibrillation, HR – 86-150 bpm, horizontal axis, deeply inverted T-waves in V2-V5, consistent with type B Wellens syndrome. Echo: mild LV dilatation, mildly reduced LV systolic function EF – 49%, no wall motion abnormalities. Admitted to the ICU, with non-STE ACS, Grace score 114. Treated with heparins, DAPT, nitrates, β-blockers, ACE-inhibitors, CCB and diuretics. Coronarography performed on the 2nd day of admission: Three-vessel coronary disease: subocclusive (99%) proximal LAD stenosis, subocclusive (90-99%) RCA II stenosis, severe (75-90%) aCX I-OM I stenosis. Syntax score 18. The patient refused surgical intervention and undergone PCI with DES of new generation in three stages. PCI on LAD performed the same day, followed by PCI on RCA in two weeks’ time and aCX after another 5 weeks. The total stents length – 131mm. Total radiation: time – 48,9min, DAP – 46,746μGy, cumulative – 6449mGy. Total contrast (Ultravist) amount 650ml. Total ICU time – 18h. Six months after complete revascularization achieved and optimal medical treatment: the patient is feeling well, the quality of life has improved, no shortness of breath at moderate exertion, no angina. Normal ECG and Echo: EF improvement – 58%. Conclusions. In elderly patients with multi-vessel coronary artery disease and low Syntax score, either revascularization procedure (PCI or CABG) on top of optimal medical therapy can be performed with good results when complete revascularization is achieved. The patients` choice for intervention should always be taken into account.