A 36-year-old male accountant went to his physician for evaluation of
chest pain. His medical history included “borderline high blood pressure,” a cigarette smoking habit of one pack per day, and a father who had coronary artery bypass surgery in his late 40s.
The patient said he had lived a relatively sedentary lifestyle for the past few years, but over the past month he started jogging. On exertion, he began to have occasional substernal chest pain, and this symptom prompted him to go to the physician for further evaluation. He had no other cardiac symptoms, including shortness of breath, lightheadedness, dizziness, palpitations, syncope, or presyncope. He had no medical problems other than being told by his physician during his last physical examination 5 years
earlier that he “had better keep an eye on the blood pressure.” Beyond 20 years of cigarette smoking and the family history of coronary disease in his father, the patient’s history was normal.
On physical examination, his blood pressure was 150/95 mm Hg, but his other vital signs were normal. A baseline electrocardiogram was also
normal. The patient underwent exercise treadmill testing, which showed
1 to 2 mm inferolateral ST-segment depression. He had severe chest pain
4 minutes into the test. On the basis of this high-risk noninvasive test, the patient underwent coronary catheterization, which revealed normal left ventricular function. Many luminal irregularities in the coronary arteries were found however, and a 90% lesion in the middle left anterior descending (LAD) coronary artery was seen.
Treatment and outcome
Because of his significant symptoms, the patient agreed to have an-
gioplasty and stenting performed on his LAD artery and says he feels tremendously better afterward. When he returned at 1 month for a follow-up visit with his physician, he was extremely grateful to his cardiologist
for “curing” him. As the cardiologist responds, what objective evidence is there to comment upon this patient’s long-term prognosis?
Most importantly, this patient has not been “cured,” but rather he may have a poor prognosis because of his diagnosis of coronary artery disease (CAD) at a young age. His overall 15-year mortality may be as high as 30%. On one hand, he is fortunate that he is not diabetic. His initial therapy with percutaneous coronary intervention may improve his prognosis. On the other hand, cigarette smoking is a major modifiable risk factor. The physician must counsel his patient on these issues.