An elderly patient taking warfarin with a mid-left anterior descending artery lesion

A 75-year-old man presented with increasing exertional chest pain over the previous few months. His cardiac risk factors included a long-standing history of dyslipidemia, for which he was receiving high-dose statin treatment. He had a history of hypertension and was a current smoker. He also had chronic atrial fibrillation, which was managed with beta blockers for rate control and warfarin (Coumadin), as well as a previous gastroduodenal ulcer (currently managed with omeprazole [Prilosec]). Electrocardiography revealed 1-mm resting ST-segment depression in leads V₃ to V₆. Results of laboratory tests for cardiac biomarkers were negative on presentation to the Emergency Department.

The patient was referred for cardiac catheterization after warfarin was withheld for 5 days, which showed a 95% mid-left anterior descending artery lesion with minor irregularities in the left circumflex and right coronary arteries. What approach would be appropriate, given his long-term warfarin use and previous peptic ulcer history? Should revascularization be attempted? If so, should surgery or percutaneous intervention be the option? Should a drug-eluting or bare-metal stent be used if a percutaneous approach is adopted? What should be the antiplatelet regimen following intervention given the patient's long-term warfarin use?