Catheterization and Cardiovascular Diagnosis 37:262 (1996)

Editorial Comment

Culprit Vessel Angioplasty: It’s a Small World After All

Joel K. Kahn, MD William Beaumont Hospital Royal Oak, Michigan

Kirigin and coworkers report in this issue a case of a non-Q wave myocardial infarction and post-infarction unstable angina associated with an isolated stenosis of a small acute marginal branch of the right coronary artery [I]. Angioplasty was performed with a 2.0 mm balloon catheter and post-procedural course was uneventful. Missing from the report is a description of the medical regimen that was prescribed for the patient. It is impossible to know whether he was truly refractory to medical therapy.

What can we learn from this report? It appears that isolated ischemia of branches supplying the right ventricle can cause an- gina and clinical instability. This has been reported in other pa- tients with disease in non-dominant right coronary arteries [ 2 ] . It demonstrates that patient care involves considerations of both pa- tient survival and quality of life. It could be argued that the ex- pense and risk of an intervention in this patient could not be

justified (or approved by a managed care gatekeeper!) as no sur- vival advantage could be expected. On the other hand, culprit angioplasty did appear to improve the patient’s lifestyle during the 9-month follow-up and was an example of compassionate patient care. It also points to another cause of angina in patients with normal myocardial perfusion imaging studies. Had this patient been evaluated for angina before his myocardial infarction with a stress imaging study, it is likely that it would have been normal and he may have been treated for presumed non-cardiac causes of chest pain. Bayes theorem is still relevant and there is a role for diagnostic coronary arteriography in patients with angina pectoris, coronary risk factors, and negative stress studies.

Kirigin and coworkers are to be thanked for reminding us that while we usually concentrate our energies on the revascularization of larger coronary arteries, when it comes to potential causes for cellular ischemia, it’s a small world after all.

REFERENCES

1 . Kirigin M, Aldridge H, Zelovitsky L, Schwartz L: Angioplasty of isolated acute marginal coronary artery disease. Cathet Cardio- vasc Diagn 37258-261, 1996.

2. Kahn JK, Bernstein M, Bengston JR: Isolated right ventricular myocardial infarction. Annals Intern Med 118:708-71 I , 1993.

0 1996 Wiley-Liss, Inc.