Conservative Medication Follow-up for Over 20 Years of a Patient With Ischemic Heart Disease After Diagnosis of Chronic Total Occlusion of the 3 Main Coronary Arteries

Abstract

A 48-year-old man suffered from acute coronary syndrome in 1978. Coronary angiography was performed at that time and showed 99% stenosis of the right coronary artery, 100% of the left circumflex branch, and 50% of the left ascending artery. He received conservative therapy. Five years later (ie, 1983), coronary angiography showed complete occlusions of the 3 major coronary arteries. Rich collateral circulation had developed distal to all 3 major coronary trees. The patient and his family rejected invasive therapies such as coronary-artery bypass graft or percutaneous coronary intervention. Cardiac catheterizations were performed in 1996, 2001, and 2007, but angiographic follow-up studies showed no change in either the coronary atherosclerosis or the collateral circulation. The left ventricular ejection fraction has been maintained at >60%. During the 20-year follow-up, he has had refractory angina, but has not suffered from acute coronary syndrome, congestive heart failure, or critical arrhythmia.

Long-Term Clinical Outcome of Chronic Total Occlusive Lesions Treated With Drug-Eluting Stents: - Comparison of Sirolimus-Eluting and Paclitaxel-Eluting Stents -

“…7-12 However, opening of total coronary occlusions can be beneficial, restoring blood flow to hibernating myocardium and thus improving symptoms and left ventricular function. 22, 23 Although there has been the rare case report of good survival of patient with CTO with only medical treatment, 24 it is generally suggested that successful revascularization of CTO lesions has a survival advantage compared with failed revascularization. 4, 5 After the introduction of DES, several studies demonstrated that the new stents markedly reduced the incidence of both angiographic restenosis and repeat revascularization in selected patients with relatively noncomplex lesions.…”

Coronary Collateral Growth and Its Therapeutic Application to Coronary Artery Disease

“…2 Thus, a significant functional role of coronary collateral circulation is now well appreciated. 8 In the past decades, 9-11 we and others have emphasized the importance of arteriogenesis of the collateral vessels for enhanced coronary collateral circulation, compared with angiogenesis of the capillaries in areas perfused by occluded or critically stenosed coronary arteries. On the other hand, there has been considerable controversy concerning the stimulus for coronary collateral growth.…”

Relationship Between Functional Exercise Capacity and Functional Stenosis in Patients With Stable Angina and Intermediate Coronary Stenosis

“…When treating patients with coronary artery disease and stable angina, the goal of treatment is complete, or nearly complete, elimination of anginal chest pain and a return to normal activity with good functional capacity. 20,21 Although PCI has become a common initial management strategy for patients with stable coronary artery disease, studies have • O2, oxygen uptake at peak exercise; AT, anaerobic threshold at the corresponding oxygen uptake.…”

“…For instance, patients with more severe angina and several coexisting medical problems may be satisfied with some reduction in the symptoms that enables them to perform only limited daily life activities. 20,21 Another investigation has indicated that 6,500-8,500 steps/day should be considered as the minimal goal and optimal level of physical activity for secondary prevention of cardiovascular disease. 22 For assessment of daily activity or for secondary prevention, CPX testing is a noninvasive guide to functional capacity and treatment efficacy.…”