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Asian Cardiovasc Thorac Ann 2000;8:364-365
© 2000 Asia Publishing EXchange Pte Ltd

CASE STUDY

Spontaneous Regression of Ostial Coronary Artery Lesion

Devan Pillay, MRCP, Zainal Abidin Abdul Hamid, MRCP

Division of Cardiology
National Heart Institute
Kuala Lumpur, Malaysia
For reprint information contact: Devan Pillay, MRCP Tel: 60 3 298 1333 Fax: 60 3 2692 8425 email: devan{at}ijn.com.my Division of Cardiology, National Heart Institute, 145 Jalan Tun Razak, Kuala Lumpur 50400, Malaysia.

   Abstract
TOP
 Abstract
Introduction
 Case Report
 Discussion
 References
 
A 47-year-old man with a positive exercise test underwent coronary angiography that showed 90% ostial left anterior descending coronary artery stenosis. The patient opted for medical therapy and included a Chinese herbal remedy that contained Ganoderma lucidum. After 2.5 years, angiography showed spontaneous regression of his coronary artery lesion.


   Introduction
TOP
 Abstract
 Introduction
Case Report
 Discussion
 References
 
The natural history of coronary artery disease is variable but true regression of coronary artery stenosis is infrequent in medically treated patients. Moreover, the pathophys-iology and clinical relevance of angiographic regression remain poorly understood. A rare case of spontaneous regression of an ostial left anterior descending coronary artery lesion, allowing successful medical treatment of symptoms and deferring intervention, is described.


   Case Report
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 Abstract
 Introduction
 Case Report
Discussion
 References
 
A 47-year-old fisherman complained of retrosternal exertional chest pain for 3 months. His only risk factors for ischemic heart disease were male gender, age, and smoking. Clinical examination was unremarkable. His resting electrocardiogram showed sinus rhythm of 60 beats•min–1 and left ventricular hypertrophy by voltage criteria. No ST-segment changes were noted. His chest radiograph revealed borderline cardiomegaly. A treadmill exercise test was strongly positive at stage II with ST-segment depression in the inferolateral leads, associated with chest pain. A coronary angiogram showed a normal left main stem and 90% stenosis of the ostial left anterior descending (LAD) coronary artery (Figures 1 and 2GoGo). The left circumflex and right coronary artery showed only minor irregularities and his ejection fraction was 68%. In spite of intracoronary nitroglycerin, the LAD lesion persisted. He was offered balloon angioplasty or minimally invasive bypass surgery. However, because of financial constraints, he opted for conservative medical treatment. He was put on metoprolol 100 mg twice daily, diltiazem 30 mg three times daily, soluble aspirin 150 mg daily, nitrates, and pravastatin 20 mg nightly. He was seen regularly in the outpatient clinic every 3 months and on one visit, he confessed that he had stopped taking pravastatin after one month. He was still getting angina occasionally but felt much better with medication. He also admitted that he was taking a concoction of Chinese herbs, the ingredients of which included the Chinese mushroom "lingzhi" (Ganoderma lucidum).



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  		Figure 1. Angiogram in left anterior oblique caudal projection at initial diagnosis. The arrow indicates a tight ostial left anterior descending coronary stenosis.

 


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  		Figure 2. Angiogram in right anterior oblique projection at initial diagnosis. The arrow indicates an ostial left anterior descending coronary stenosis.

 
After 2.5 years, he finally agreed to undergo bypass surgery at the insistence of his friends who warned him that he might "drop dead" anytime. He underwent a repeat coronary angiogram prior to bypass surgery. Surprisingly, the ostial LAD lesion had totally regressed (Figures 3 and 4GoGo). There was mild disease progression in the other arteries but his left ventricular function was well preserved. He was still on herbal treatment and continued to smoke although he had cut down the number of cigarettes per day considerably. He has remained in good health and angina-free.



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  		Figure 3. Left anterior oblique caudal projection 2.5 years later, showing complete regression of the ostial stenosis.

 


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  		Figure 4. Right anterior oblique projection 2.5 years later showing regression of the ostial stenosis.

 

   Discussion
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 Abstract
 Introduction
 Case Report
 Discussion
References
 
Aggressive lowering of serum cholesterol has been shown to slow progression of atherosclerosis, reduce new lesion formation, and decrease clinical cardiac events.1 There is strong evidence to support the use of statins to lower serum cholesterol and retard progression of atheroscle-rosis.2–4 Various mechanisms may be involved, including plaque stabilization, antioxidant effects, and improved coronary vasomotor tone. The MAAS study suggested that coronary arteries with diffuse focal atherosclerosis progress at the same rate in both stenosed and nonstenosed segments.1 This case is interesting because the patient's coronary artery disease regressed spontaneously. The initial lesion was unlikely to be due to catheter-induced spasm as the diagnostic catheter was well away from the ostium of the LAD and the left main stem was well visualized. Furthermore, intravenous nitroglycerin did not improve the angiographic appearance. Interestingly, the patient admitted to having stopped pravastatin one month after diagnosis and this short duration of treatment is surely not sufficient for coronary artery disease regression. Herbal medication has been claimed to cure a host of ailments and perhaps its role in the regression of coronary artery disease needs further evaluation. This case clearly illustrates that even severe de novo coronary artery lesions can regress spontaneously. The mechanisms of disease regression need to be clearly elucidated.


   References
TOP
 Abstract
 Introduction
 Case Report
 Discussion
 References
 

  1. Vos J, de Feyter PJ, Kingma JH. Evolution of coronary atherosclerosis in patients with mild coronary artery disease studied by serial quantitative angiography at 2 years and 4 years follow-up. The Multicenter Anti-Atheroma Study (MAAS). Eur Heart J 1997;18:1081–9.[Abstract/Free Full Text]

  2. Merz CNB, Rozanski A, Forrester JS. The secondary prevention of coronary artery disease. Am J Med 1997; 102:572–81.[Medline]

  3. Waters D, Pederson TR. Review of cholesterol lowering therapy. Coronary angiographic and event trials. Am J Med 1996;101:35–9.

  4. Aengevaeren WR, Uijen GJ, Jukema JW, Bruschke AV, van der Werf T. Functional evaluation of lipid-lowering therapy by pravastatin in the Regression Growth Evaluation Statin Study. Circulation 1997;96:429–35.[Abstract/Free Full Text]





This Article
Right arrow Abstract Freely available
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Right arrow Alert me when this article is cited
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Right arrow Articles by Pillay, D.
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Right arrow Articles by Pillay, D.
Right arrow Articles by Abdul Hamid, Z. A.

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