Atherosclerosis follows a general hemodynamic rule.
It has a predilection for medium and small sized vessels and love to home in on the branch points .
We know coronary artery disease mainly involve the proximal tree. We get occasional patient with mid or distal CAD.
This again , in combination with atleast one proximal lesion. Decision making is easy if there is critical proximal lesion.
Here is a patient who has isolated critical distal CAD . He created a heated debate in our cath meet
His LV function was normal , He had TMT borderline positive , but no angina ,
What has to be done for him ?
A fellow suggested a thallium
It was countered by other , we can take it as granted there is cold spot in thallium in a small posterior segment , then how will you proceed ?
- PCI, medical , CABG ?
- CABG definitely not ,
- PCI . . . may be . . .Medical may be !
When you are confused about the choice and outcome . . .confuse the patient* as well ! And , let him decide after a mini , (but exhaustive ) lecture on coronary blood flow , risk of heart attacks etc .
So in this modern era of pseudo empowerment , it is ironical patients will prevail over doctors after learning half or quarter truths from their android powered smart phones and i pads !
By the way finally what was decided ?
The patient and overwhelming majority voted for a drug eluting stent for the OM lesion event as it appears technically a bifurcation lesion ! This is how cardiology is practiced.
Reference:
Isolated distal coronary artery disease. Presented in cardiological society of India meet 2005
A clarification .
** One definition for “confusion” is being in a “unclear” state of mind !
**The aim of this blog is never to confuse the patient. The above statement is necessary because many patients do believe(or rather want to) they understand every thing about their illness even as doctors are baffling with the great uncertainties and intricacies of most medical conditions.
Can medical management convert TMT positive into negative ?
Dr.S.Venkatesan MD 
Sir,
sometimes your information is very confusing. Why did you do a TMT for an asymptomatic patient. If the TMT was done for symptoms of angina, and if the TMT was positive and if he has this lesion than a PCI is waranted for symptom control.
Hi
I think , you should realise, TMT done for asymptomatic persons is the commonest indication currently carried out for screening CAD.
TMT can be equivocal/Borderline positive in 30% (Thats what he had )
So , CAG was done and this lesion was detected.
And the dilemma is , does this lesion can be treated by drugs alone ?