Relentless Angina of a Scarred Heart

Refractory anginal pain affects nearly 5-10% of stable coronary artery disease patients, and maximizing the anti-ischemic medical therapy is the standard first-line treatment. The presence of a scarred myocardial territory of the epicardial coronary chronic total occlusion (CTO) limits the implementation of other modalities, such as angioplasty and surgical bypass. Accordingly, this subset of patients, who show poor response to medical treatment with the absence of considerable reversible ischemia, bears an additional burden of persistent angina besides the structural and functional complications resulting from their scarred hearts. In this report, a patient, with compensated ischemic cardiomyopathy, complaining of disabling stable angina was indicated for diagnostic coronary angiography that showed a chronic total occlusion (CTO) at the mid-segment of the left anterior descending coronary artery (LAD) and otherwise no significant stenoses in the epicardial coronary tree. After the failure of maximized anti-ischemic medical therapy, the patient underwent elective percutaneous intervention (PCI) to the left anterior descending coronary artery (LAD) chronic total occlusion (CTO) with 2 overlapping drug-eluting stents that yielded a favorable outcome on patient follow-up even though a myocardial perfusion imaging failed to show considerable reversible ischemia at the left anterior descending coronary artery (LAD) territory. The report points out that elective chronic total occlusion (CTO) revascularization may alleviate anginal pain, despite the absence of a considerable macroscopic ischemia, after failure of a maximized anti-ischemic medical regimen.