Should intervention be considered for an intermediate flow-limiting coronary lesion that does not correlate with perfusion defects on stress testing in a patient with atypical anginal symptoms?  

This is a kind of question that gets into the realm of the "art of medicine". There are multiple questions within this single question. I will try to answer each of them. What is an angina and what is atypical angina: I have come across a wide variety of angina syndromes throughout my clinical ex...

Patients experience angina very differently though the recent chest pain guidelines have tried to dispel the notion of "atypical" angina and move toward a paradigm of cardiac vs. noncardiac symptoms. Nuclear stress testing frequently has false positives and defects which do not correlate with invasi...

I would not intervene since there is no evidence to show that intervention prevents mace in patients with very low LDL levels. I would get this patient’s LDL less than 30 if possible.

This is a difficult question made simple by the fact that ‘a patient with CP has a flow limiting lesion’. The specificity of SPECT MPI or SE, etc. is somewhere north of 85% in general, so neither are the gold standard tests. An abnormal stress test or an abnormal functional study allows ...

If we have made it to the Cath Lab with this type of patient, physiology utilizing Fractional flow (IFR, RFR, IFR…) may help decision-making in this patient with atypical symptoms and noncongruent stress test. The capabilities of doing these functional studies now with CCTA is also useful.

How likely is it that PCI will relieve the symptoms as opposed to medical treatment? That’s the dilemma because if no there’s no relief you now have a stent in place and little to show for it. Therefore, prior to intervening, I would exclude every other cause of atypical symptoms. 

If the lesion is not in the territory where nuclear medicine results were positive then this means the nuclear stress test was false positive and you should not consider the result in decision-making after visualizing the stenosis. Assuming medical therapy has been properly maximized, you take the p...