Table 1 Clinical vignette patients and their characteristics

Smith

“Mr. Smith is a 69-year-old with class III stable angina. He first noticed his chest was tight during his daily swim at the rec center a year ago. After his sister prodded him, he went to the doctor and tried out different medications. He had a lot of side effects and struggled to find medications that worked for him. He settled into taking aspirin and a beta blocker and most of the time takes a calcium channel blocker. He still gets chest pain sometimes and avoids one of his favorite hunting spots because there’s a big hill. After discussing his lingering symptoms and disappointment with medications with his cardiologist, he is scheduled for a stress test. His stress test shows evidence of ischemia and his ECHO shows normal ventricular function and no valve disease. He undergoes a cath. At his cath they find an 80% LAD stenosis, 65% circumflex stenosis, and 90% RCA stenosis.”

Male

69 years old

Rx: aspirin, beta blocker, calcium channel blocker

80% LAD, 65% circumflex, 90% RCA

Adams

“Mrs. Adams is 81 years old. She is diabetic and her hemoglobin A1c has been regularly under 7.2% for years. In addition to her diabetes medication, she takes aspirin, a statin, and a beta blocker. She has class III stable angina and is mainly bothered by her chest pain when she is working in her garden. Although her symptoms haven’t changed recently, her cousin had a heart attack last month and at her check-up with her cardiologist she asked if she could do something more for her heart. She has normal ventricular function and no valve disease. She and her cardiologist decide it is time to proceed with a cath and she is scheduled for the next week. During a diagnostic cath, they find an 80% LAD stenosis, a 30% diagonal stenosis, and 75% circumflex stenosis.”

Female

81 years old

Diabetic

Rx: aspirin, statin, beta blocker,

80% LAD, 35% diagonal, 75% circumflex

Jones

“Mr. Jones is a 63-year-old male. He has been managed medically for stable angina for 3 years. His wife makes sure he takes his aspirin, an ACE inhibitor, and a beta blocker but lately feels like his medications don’t do as much as they used to. He is not diabetic. Two days ago his chest pain got worse than normal while on his typical evening walk with his wife. His chest pain didn’t go away as quickly as usual and lingered through the morning when they decided to go to the hospital. After he was admitted he had an ECG. It showed no ST or TW changes and his troponins came back normal. He is scheduled for a cath the following morning. By the next morning his chest pain is not bothering him anymore, but he and his wife are concerned enough about his symptoms that they want to proceed with a cardiac cath. The cath shows an 85% LAD stenosis, a 60% circumflex stenosis, and a 75% RCA stenosis. His LV gram shows normal ventricular function and no valve disease.”

Male

63 years old

Rx: aspirin, ACE inhibitor, beta blocker

Unstable angina

85% LAD, 60% circumflex, 75% RCA