Improvement of angina after treating focal coronary artery disease undetected in resting conditions.

Abstract

A 65-year-old woman without cardiovascular risk factors presented with stable angina Canadian Cardiovascular Society (CCS) Class II. The 7-item Seattle Angina Questionnaire (SAQ-7) indicated frequent angina, moderate physical limitation, and low quality of life for a summary score of 50/100. Coronary CT and invasive angiography revealed severe stenosis in the mid-left anterior descending (LAD) coronary artery with a minimum lumen area (MLA) of 0.9 mm2 and mixed plaque (Figures 1A and B). Intravascular ultrasound (IVUS) confirmed small MLA and 84% plaque burden (Figure 1A, right panels). The resting full-cycle ratio (RFR) was negative (0.93), whereas fractional flow reserve (FFR) was positive (0.75) with a focal pressure step-up in the pullback curve as quantified by a high pullback pressure gradient (PPG) index of 0.79 (Figures 1C and D). The patient underwent percutaneous coronary intervention (PCI) with one drug-eluting stent (Figure 1E). Post-PCI IVUS confirmed good stent expansion. Post-PCI FFR increased to 0.92 without residual focal pressure gradients in the pullback curve (Figure 1F), and normal microcirculation function demonstrated by a coronary flow reserve (CFR) of 7.8 and index of microvascular resistance (IMR) of 16 (Figure 1G). RFR remained unchanged at 0.94. The SAQ-7 at 1-year follow-up showed complete symptoms resolution and improvement in all domains (Figure 1H). A symptomatic patient with obstructive focal epicardial disease yet a negative resting index experienced relief from angina after PCI. This case highlights the usefulness of a comprehensive physiological assessment in cases considered for revascularization, particularly with focal lesions.