In late October, we presented the case of a patient with stable coronary artery disease in Clinical Decisions,1 an interactive feature designed to assess how readers would manage a clinical problem for which there may be more than one appropriate treatment. Our patient was a 65-year-old man with hypertension, obesity, and type 2 diabetes who presented with a 2-week history of exertional angina. He underwent an exercise-tolerance test on a treadmill, along with myocardial perfusion imaging, which showed a fixed anterior defect and a reversible anterolateral defect, both of moderate size. His subsequent cardiac catheterization revealed an occluded first diagonal branch, a long lesion with 70% stenosis in the midportion of the left anterior descending coronary artery, a calcified lesion with 80% stenosis in the proximal left circumflex coronary artery, and 50% stenosis of the posterior descending coronary artery. These findings were accompanied by anterior-wall hypokinesis and an ejection fraction of 45% by left ventriculography.
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This is clearly a controversial area; more data on symptomatic but stable coronary artery disease are needed to direct clinical decisions. As we await such data, it appears that current approaches will continue to vary on the basis of an integration of physicians' experience and knowledge with patients' preferences. Given a clinical problem without a clear solution, many respondents appropriately noted the importance of discussing with the patient all treatment options and their possible outcomes.
Comments from this interactive feature will remain available at www.nejm.org, along with data on the voting results. We thank you for your input, and we look forward to hearing from you again soon about another challenging case.
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