From the Case Discussions: Right Coronary Disease, Renal Failure and HIV in Coronary Artery Disease

The most specific material in Dr. Biswarup Purkayastha's masterclass came out of direct case discussions with the general practitioners attending, rather than the prepared slides. Several exchanges in particular show how his framework for coronary artery disease gets applied to real, ambiguous patients.

The 38-year-old with two years of unexplained chest pain

Dr. Boris Pachinko, a general practitioner in Zambia, described a 38-year-old male patient with two years of intermittent chest pain accompanied by shortness of breath and weakness severe enough that the patient would bang on a wall to summon help when alone. Two ECGs were largely unremarkable (one showed borderline bradycardia), two echocardiograms showed only mild mitral regurgitation with normal ejection fraction, blood work including a full liver and renal panel was normal, and a 24-hour Holter picked up only low-frequency premature atrial and ventricular contractions. A CT coronary angiogram was not available locally.

Purkayastha's read: the bradycardia on one ECG, combined with a presentation that resists diagnosis on standard blood work and imaging, is consistent with right coronary artery disease, which he had already flagged elsewhere in the session as the harder of the two coronary territories to pick up outside of direct angiography. His recommended plan, pending access to a coronary angiogram: dual antiplatelet therapy (clopidogrel 75 mg and aspirin 150 mg daily), a statin at 40 mg daily (atorvastatin or rosuvastatin) to stabilize the coronary plaque, and cardiac enzyme testing at the patient's next chest pain episode. A positive enzyme without an ECG change would classify the patient as having unstable angina, since unstable angina, by definition, does not require an ECG change, only a troponin derangement alongside chest pain. He also noted the patient's strong maternal family history of cardiac illness as a relevant risk factor despite the patient's young age and absence of smoking or alcohol use.

An outdated risk score

In a follow-up question, Dr. Boris asked about a risk-scoring tool he could not initially name, later identified as the RFCL (risk factor weighted clinical likelihood) score, which had placed the same patient at 10 percent. Purkayastha's response was unambiguous: RFCL is an outdated scoring system no longer in clinical use, prone to false negatives, and he recommended the SYNTAX score (once angiography is available) or the EuroSCORE instead.

A 70-year-old on long-term dialysis with a new NSTEMI

Dr. Hiwot, from Ethiopia, described a 70-year-old diabetic patient with end-stage renal disease on hemodialysis for three and a half years, maintained on aspirin and atorvastatin, admitted with intermittent chest pain and a diagnosis of NSTEMI. Purkayastha's plan: single antiplatelet therapy (aspirin), unfractionated heparin, specifically avoiding low molecular weight heparin because it recirculates in patients with compromised renal clearance, dosed roughly three times a day for about two weeks to stabilize the acute presentation. Only once symptoms settle and the patient has cleared his next dialysis session should a coronary angiogram be planned, at which point the decision between stenting and bypass can be made. Purkayastha's default for a frail, elderly diabetic dialysis patient in this position leans toward stenting, since it offers a faster route to stabilization than an operation this patient may not tolerate well.

HIV and coronary intervention

Asked by Dr. Ivan Ipavu how to manage angina in a patient with HIV, Purkayastha was direct that HIV status does not change access to treatment: the patient undergoes coronary angiography under universal precautions, and a JCI-accredited hospital, including his own, has protocols to isolate and appropriately manage such patients through either stenting or bypass surgery without discrimination in the level or quality of care provided.

Pectoralis muscle spasm versus coronary spasm

Dr. Dimma, from Ghana, asked how to differentiate pectoralis muscle spasm from a genuine coronary event, and separately, whether a coronary spasm could trigger a pectoralis muscle spasm. Purkayastha's answers: troponin is the differentiator for the first question, since a pectoralis muscle spasm always returns a negative troponin test, while a true coronary event does not; and no, a coronary spasm does not cause a pectoralis muscle spasm, since the two are anatomically and mechanistically unrelated. Practically, a pectoralis spasm can be aggravated by a localized range-of-motion test, such as reaching behind the back, while true angina is unaffected by arm or shoulder movement. He added that pectoralis muscle spasm is managed with non-steroidal anti-inflammatory drugs, while a confirmed coronary event follows the angiography pathway described elsewhere in this series.