Case 1: The 88-Year-Old in the Cath Lab

An aspirin-allergic woman, a CT scan, a same-day protocol, and a stent in the artery that keeps the front wall of the heart alive.

The Presentation

She arrived at the allergy clinic at eight in the morning.

She was 88 years old, four feet eleven, one hundred fifty-five pounds, wearing a cardigan she had buttoned wrong in the front. Her daughter had driven her from the small town where she lived, forty minutes north. The appointment at the allergy clinic had been scheduled three weeks before this day, and the cath lab appointment was scheduled for that same afternoon, contingent on what happened in the morning.

That contingency was the point. She had a blocked artery. She was allergic to aspirin. The two facts created a problem, because you cannot safely place a stent in a coronary artery without aspirin. The stent requires dual antiplatelet therapy, aspirin plus a second agent, to prevent the catastrophic blood clot that forms inside a freshly deployed metal scaffold in the first days after the procedure. Without aspirin, that clot forms. With it, the risk drops to acceptable. But first, she had to be desensitized.

The allergy, according to her medical history, was reported as hives. It had developed more than thirty years earlier. She had taken aspirin once, at some point in her sixties, and had broken out in hives. Since then she had avoided the drug entirely, a reasonable precaution at the time. She also avoided ibuprofen and indomethacin, which are chemically related to aspirin in the NSAID class. The avoidance had been durable, thorough, and, until her coronary arteries started narrowing significantly, clinically unimportant.

The coronary artery narrowing had been found three months before this day.

She had come to her cardiologist’s office in the winter complaining of shortness of breath when she carried laundry. Not chest pain. Shortness of breath. She was 88 years old and had lived alone since her husband had been moved to a memory care facility. She carried her own laundry bags. When she climbed the stairs with them, she had to stop. That symptom had been present for several months before she mentioned it to anyone. She had attributed it to getting older.

The echocardiogram ordered at that clinic visit had shown a heart with a mildly reduced ejection fraction of 45-50 percent. That meant the heart was pumping slightly less blood per beat than it should. It also showed regional wall motion abnormalities: specific areas of the heart muscle that were moving less than the rest, a pattern consistent with reduced blood supply to those segments. The inferoseptal and apical segments of the left ventricle were the problem areas. Those segments are supplied by the left anterior descending coronary artery.

The next step was a coronary CT angiogram. It was scheduled, performed, and then interpreted by two physicians: the radiologist who read the images and the cardiologist who added the functional layer. The functional layer was a HeartFlow FFRct analysis, which takes the coronary CT images and uses computational fluid dynamics to calculate the pressure drop across a stenotic lesion without a catheter or a wire. The result came back: the left anterior descending artery (LAD) showed an FFRct of 0.68 in its territory. Below 0.80 is the threshold for hemodynamic significance. The LAD was significantly narrowed. The calcium score was 505, placing this patient at the 70th percentile for coronary calcium burden among women in her age group. The RCA had moderate disease but an FFRct of 0.82, above the ischemic threshold.

The cardiologist’s note following the CT result said: she will need aspirin desensitization before any intervention. The allergy clinic was contacted. The schedule was built. She had been waiting three weeks for this morning.

Now she was in the chair at the allergy clinic, the nurse dissolving an Alka-Seltzer tablet (which contains 325 mg of aspirin along with sodium bicarbonate and citric acid) in 100 mL of tap water. The solution was 3.25 mg/mL. The nurse had reviewed the procedure with her. She had asked one question.

“Do I have to do this to get the procedure today?”

The nurse said yes.

She said: “Then let’s start.”

The First Look

The cardiologist had reviewed her chart before the cath lab appointment. By the time she arrived in the pre-procedure area at noon, the clinical picture was complete.

She was 88 years old. Her blood pressure was 161/74, which was high by any definition but not unusual for an octogenarian with longstanding hypertension on two antihypertensive agents (lisinopril 2.5 mg and hydrochlorothiazide 12.5 mg). Her heart rate was 65, which reflected the effect of metoprolol succinate 25 mg daily. Her oxygen saturation was 99 percent on room air. She had completed aspirin desensitization three hours earlier, tolerating the graduated dosing protocol without adverse reaction: no urticaria, no bronchospasm, no anaphylaxis. The allergy physician had cleared her for the afternoon procedure.

The ECG showed sinus bradycardia at 46 beats per minute, low voltage QRS, and a pattern the reading cardiologist described as “cannot rule out anterior infarct, age undetermined.” Low voltage on an ECG in an elderly person carries several possible explanations: obesity, emphysema, pericardial effusion, or prior myocardial infarction with replacement of viable myocardium by scar. In this patient, the echocardiogram had already shown akinesis of the apical septal and apical segments, consistent with prior LAD territory injury. The ECG finding was not a surprise; it was a confirmation.

Her laboratory data, drawn four days before the procedure, showed a hemoglobin of 12.1 g/dL, within the mild anemia range typical in elderly women. Her creatinine was 1.30 mg/dL, with a GFR of 39 mL/min/1.73 m2 by CKD-EPI 2021 equation, consistent with stage 3b chronic kidney disease. Her potassium was 4.4 mEq/L. Her platelets were 254,000.

The GFR of 39 mattered for the procedure. Iodinated contrast used in coronary angiography is nephrotoxic in proportion to dose and to baseline renal function. A GFR of 39 placed this patient in the moderate risk category for contrast-induced nephropathy 5 / Solid . The procedural team would need to minimize contrast volume and consider pre-procedure hydration.

The echocardiogram from three months before the procedure had documented: left ventricular ejection fraction 45-50 percent, mild concentric left ventricular hypertrophy with septal wall thickness of 1.04 cm and posterior wall thickness of 1.04 cm, regional wall motion abnormalities with hypokinesis of the basal and mid inferoseptal segments and akinesis of the apical septal, apex, and apical lateral segments. The LA volume index was 32 mL/m2, above the normal upper limit of 28 mL/m2, consistent with diastolic dysfunction. The E/E’ ratio was 17, suggesting increased left ventricular filling pressures. There was mild mitral regurgitation and mitral annular calcification. There was mild tricuspid regurgitation and mild pulmonary hypertension (estimated PA systolic pressure 30 mmHg by the TR gradient). The left ventricular end-diastolic pressure measured at the start of the procedure was 5 mmHg, which was normal.

The coronary CT angiogram had shown: total calcium score 505 with the LAD accounting for a calcium score of 338 out of 505 (two-thirds of the total calcium burden concentrated in the single vessel that was already hemodynamically compromised). The LAD had tandem moderate-to-severe stenoses throughout its proximal, mid, and distal segments. The HeartFlow FFRct analysis: LAD 0.68 (hemodynamically significant, below the 0.80 ischemic threshold), RCA 0.82 (above threshold), LCX normal.

The clinical picture that entered the pre-procedure assessment was this: an 88-year-old woman with successfully treated aspirin hypersensitivity, moderate chronic kidney disease, mild LV systolic dysfunction with a pattern of regional wall motion abnormalities consistent with LAD territory ischemia, and a heavily calcified LAD with FFRct-confirmed hemodynamically significant stenosis. The Syntax score, calculated from the coronary CT, was less than 22, placing the case in the low-complexity category.

The interventional cardiologist assessed her, reviewed the consent, confirmed she understood the risks (bleeding, infection, procedural MI, stroke, acute kidney injury, radiation, and death), and confirmed she wished to proceed.

The procedure began at 1:28 PM.

The Workup

The workup for this case had unfolded over four months. Understanding it requires following the sequence in the order it occurred, because each result changed what came next.

November 2025: The First Cardiology Contact

She was seen by a cardiology advanced practice provider for evaluation of an echocardiogram ordered by her primary care physician, which had shown mitral regurgitation and prompted a referral. The ECG at that visit showed sinus bradycardia, low voltage QRS, and a borderline pattern. The echocardiogram at that visit had not yet been done at the cardiology center; it was performed in early October and received from an outside system. Its findings, as described above, were significant: a mildly reduced ejection fraction of 45-50 percent with regional wall motion abnormalities in the LAD distribution.

The finding of regional wall motion abnormalities in the LAD territory in the setting of low voltage on ECG and mild LV systolic dysfunction created a clinical question that the echocardiogram could not answer: was this pattern due to active ischemia from hemodynamically significant LAD stenosis, or was it due to prior infarction with scar? The symptoms (exertional dyspnea) were consistent with either. The distinction mattered, because significant active ischemia from an obstructive LAD lesion is potentially reversible with revascularization, whereas scar does not recover.

The traditional approach to answering this question would have been stress testing. But the PROMISE trial had already demonstrated that coronary CTA was at least as good as functional stress testing for detection of obstructive CAD in symptomatic outpatients 5 / Solid . The SCOT-HEART trial had shown that coronary CTA added incremental prognostic information beyond functional testing and standard care, reducing the rate of fatal MI or nonfatal MI at 5 years 5 / Solid . And in this patient, stress testing carried its own limitations: her submaximal exercise capacity (she was 88, short of stature, and had exertional dyspnea) and the presence of low voltage on baseline ECG, which can reduce the sensitivity of exercise ECG interpretation.

The decision was coronary CTA with FFRct. The scan was scheduled for March 2026.

March 2026: The Coronary CT Angiogram

The scan was performed at the cardiology center. Premedication: metoprolol 100 mg orally one hour before, to reduce heart rate to a range allowing good image quality. Sublingual nitroglycerin 0.8 mg at the start of scanning, to dilate the coronary arteries and improve visualization. Heart rate at imaging: 62 beats per minute.

The calcium score was 505 by the Agatston method. The LAD score was 338. A calcium score of 505 placed this patient at the 70th percentile for her age and sex group, meaning 30 percent of women her age had a higher score 5 / Solid .

The coronary anatomy: right dominant circulation. Left main: mild mixed plaque, less than 25% stenosis. LAD: severe disease throughout, with heavy mixed plaque burden including multiple soft plaque elements. Tandem stenoses of at least moderate degree (50-69%) in the proximal, mid, and distal LAD segments. First diagonal branch: moderate mixed plaque with moderate stenosis (50-69%). LCX: non-dominant, mild plaque with mild stenosis (25-49%). RCA: large caliber, dominant, moderate soft-predominant plaque with at least moderate stenosis (50-69%) in the proximal and mid segments.

The reading radiologist reported the impression: multivessel obstructive CAD with high-risk features (LAD and RCA involvement), and recommended functional assessment with FFRct. The cardiologist’s addendum, completed after the HeartFlow analysis: LAD FFRct 0.68, below the ischemic threshold. RCA FFRct 0.82, above the threshold. LCX normal. Functional ischemia in the LAD territory. The recommendation: consider early invasive evaluation and revascularization planning.

April 2026: The Results Discussion

She was seen by the cardiology APRN for a results discussion appointment, accompanied by her daughter. The CCTA results and the FFRct addendum were reviewed in detail. The clinical plan documented at that visit: referral to allergy and immunology for aspirin desensitization, heart catheterization to follow once desensitization was complete. A statin was added to her regimen: rosuvastatin 20 mg daily, consistent with ACC/AHA guideline recommendations for secondary prevention equivalent in a patient with documented obstructive CAD 5 / Solid .

At that visit, she and her daughter asked whether she could have a Xanax for anxiety. Her husband was in a memory care facility. She was not sleeping. She mentioned the Xanax request matter-of-factly, as one item on a list of things she needed addressed, alongside the stent. The APRN noted the request and the clinical context (husband in memory care, sleep difficulty, situational anxiety) in the chart.

The cardiac workup was complete. The clinical question was answered: hemodynamically significant LAD stenosis in the setting of mild LV dysfunction, regional wall motion abnormalities, exertional dyspnea, and aspirin hypersensitivity. The intervention was planned. The aspirin barrier had to be addressed first.

The Differential

The clinical team faced two differentials simultaneously: the diagnostic differential (was the LAD stenosis truly causing the symptoms?) and the management differential (given that it was, what was the right treatment?).

The Diagnostic Differential

The ISCHEMIA trial enrolled 5,179 patients with stable ischemic heart disease and at least moderate ischemia on stress testing, randomizing them to an initial invasive strategy versus OMT 5 / Solid . At a median follow-up of 3.3 years, the invasive strategy did not reduce the primary composite endpoint of cardiovascular death, MI, hospitalization for unstable angina, hospitalization for heart failure, or resuscitated cardiac arrest compared to OMT.

ISCHEMIA applies here: this patient had stable ischemic heart disease with FFRct-confirmed hemodynamically significant LAD stenosis and exertional symptoms consistent with CCS Class II angina (typical symptoms with moderate exertion). The ISCHEMIA result was not a finding that intervention is wrong. It was a finding that the timing and selection pressure for immediate invasive management in stable disease should be reconsidered, and that symptom burden (which ISCHEMIA did show was improved by the invasive strategy) and patient preference are legitimate drivers of the management decision.

The PLATFORM trial had specifically evaluated coronary CTA with FFRct versus functional testing in the same kind of patient and found that the FFRct-guided approach led to fewer invasive procedures overall, with non-inferior clinical outcomes 5 / Solid . An FFRct of 0.68 in this context represented not only anatomic disease but functionally significant stenosis: the kind that produces ischemia under stress, consistent with the symptoms this patient reported.

The management differential:

Option 1: Guideline-directed medical therapy alone (OMT). ISCHEMIA showed OMT was non-inferior to the invasive strategy for hard cardiovascular endpoints in stable disease. However, OMT did not improve quality-of-life outcomes as effectively as the invasive strategy in patients with moderate-to-severe ischemia at baseline. This patient had exertional dyspnea limiting her ability to carry laundry. She was already on maximally tolerated medical therapy for her age and renal function (metoprolol, low-dose lisinopril, rosuvastatin, low-dose hydrochlorothiazide). A nitrate could be added for symptom management, but the underlying LAD anatomy was severe enough that the symptom burden was unlikely to resolve with medication alone.

Option 2: Percutaneous coronary intervention. PCI to the culprit LAD was supported by the FFRct result, the symptom profile, the Syntax score (less than 22, low complexity), and the absence of left main or three-vessel disease that would favor CABG over PCI in a younger patient. The FAME 2 trial showed that FFR-guided PCI for hemodynamically significant lesions (FFR less than or equal to 0.80) reduced the rate of urgent revascularization compared to OMT alone 5 / Solid . For this specific patient, the FFR-equivalent result (FFRct 0.68, well below 0.80) provided the functional justification for proceeding.

Option 3: Coronary artery bypass grafting. CABG was not favored in this clinical context. The patient was 88 years old with a GFR of 39 and mild LV dysfunction. The STS-PROM mortality score for isolated CABG in an 88-year-old woman with these comorbidities would be estimated at 5-8%. The SYNTAX trial and its extended follow-up showed that CABG was superior to PCI for three-vessel and left main disease with higher Syntax scores 5 / Solid 60137-3). With a Syntax score below 22 and single-vessel culprit disease (LAD), PCI offered an equivalent expected outcome with substantially lower procedural risk.

The RCA question: The RCA showed 70% stenosis by angiography with an FFRct of 0.82, above the ischemic threshold. The clinical team documented the plan to consider staged PCI to the RCA if clinically indicated after the LAD intervention. The decision was: address the culprit lesion (LAD) first, reassess the RCA symptom contribution after recovery.

The clinical team committed to IVUS-guided PCI of the LAD.

The Pivot

Two pivots defined this case. The first was the FFRct result. The second was the aspirin allergy.

The FFRct of 0.68 was the diagnostic pivot. Below 0.80, the lesion is hemodynamically significant by the PLATFORM trial definition 5 / Solid . The FAME trial had established 0.80 as the functional threshold using wire-based FFR: lesions below 0.80 produced ischemia under stress, lesions above 0.80 did not, and PCI was only beneficial for the former 5 / Solid . FFRct, derived computationally from the CT images, correlates with wire-based FFR with reasonable diagnostic accuracy (area under the ROC curve approximately 0.90 in the NXT trial, Solid; 10.1001/jama.2014.542). An FFRct of 0.68 is unambiguous: this lesion was producing functional ischemia.

The aspirin allergy was the logistical pivot. Without it, this case would have been scheduled for coronary angiography and possible PCI in a standard single-session procedure. The aspirin allergy created a sequencing problem. Dual antiplatelet therapy is required after DES implantation for a minimum of 6 months (and longer if tolerated) to prevent stent thrombosis, which carries a mortality of approximately 25-45% 5 / Solid . Without aspirin, the stent thrombosis risk is substantially higher, because ticagrelor or clopidogrel alone is not equivalent to dual antiplatelet therapy.

Aspirin desensitization is the solution for this clinical problem. The published literature on rapid aspirin desensitization for cardiac procedures documents success rates above 95% using graduated dose protocols 5 / Solid . The mechanism of aspirin hypersensitivity in the absence of aspirin-exacerbated respiratory disease (AERD) or chronic inducible urticaria (CIU) is typically a low-grade non-IgE-mediated reaction, which loses its reactivity when the patient is exposed to graduated increasing doses over a supervised period. Once desensitized, the patient maintains tolerance as long as she takes aspirin daily without a gap exceeding 48 hours.

The allergy physician at this center had classified her hypersensitivity as low risk for the desensitization procedure: no history of AERD (she had COPD noted in the pre-procedure note but no aspirin-exacerbated respiratory disease pattern, and asthma was listed as well-controlled), no chronic inducible urticaria, no previous anaphylaxis, and no prior failed desensitization. She underwent rapid desensitization on the morning of the procedure: four oral doses of dissolved aspirin (3.25 mg, 16.25 mg, 32.5 mg, and 65 mg) separated by 30-minute observation periods, followed by 81 mg, and then 162 mg (two 81 mg tablets). Total aspirin administered: 243 mg. Total observation time: approximately four hours. She tolerated every dose without adverse reaction. Her post-desensitization instruction: take aspirin 81 mg daily starting the following morning, without interruption.

She then walked from the allergy clinic to the heart center for the 12:30 PM pre-procedure evaluation.

The Procedure

Right radial artery access was chosen. The choice of radial over femoral access was driven by the published evidence and the specific clinical characteristics of this patient.

Why Radial Access

The MATRIX trial (8,404 patients, ACS) showed that transradial PCI reduced net adverse clinical events compared to femoral access, primarily by reducing bleeding complications 5 / Solid . In elderly patients specifically, the femoral access site carries higher bleeding risk because the common femoral artery is often calcified and the patient may not be able to remain supine for the manual compression or closure device period required after femoral access. The RIVAL trial showed the radial access advantage was most pronounced in patients at high bleeding risk, which includes patients over 75 with multiple comorbidities 5 / Solid 60404-2). At 88 years old, this patient was in the highest-risk demographic for femoral access site complications.

The Procedure Sequence

Arterial access was achieved at the right radial artery with a small-caliber sheath. Verapamil 2.5 mg was administered intra-arterially to prevent radial artery spasm, which is more common in older women with smaller caliber radial arteries. Lidocaine 1% was used for local anesthesia. Moderate sedation was achieved with fentanyl 50 mcg and midazolam 1 mg intravenously.

Heparin anticoagulation: 5,000 units intravenously at the start of the case, with additional doses totaling 8,000 units, maintaining activated clotting time (ACT) in the therapeutic range throughout the case. Heparin was chosen over bivalirudin based on the standard approach for elective PCI; no particular contraindication to heparin was present, and the BRIGHT-4 trial did not demonstrate superiority of bivalirudin over heparin for this clinical scenario 5 / Solid 01940-6).

Contrast used: iopamidol (Isovue-370), 130 mL total. For a patient with GFR 39, the maximum recommended contrast volume is generally 2-3 times the GFR (78-117 mL for a GFR of 39 by some formulas). At 130 mL, this case approached the upper limit; intravenous hydration with 500 mL normal saline was administered during the case to mitigate contrast nephropathy risk 5 / Solid .

Fluoroscopy time: 20.3 minutes. Total radiation dose: 59.130 Gy-cm2 (reference air kerma 851 mGy). These values are within the expected range for a complex multi-vessel angiography case with IVUS guidance.

Coronary Angiography Findings

Left main: large, minimal luminal irregularities on angiography, consistent with the CTA appearance. IVUS of the left main showed moderate plaque.

LAD: the vessel was large caliber, moderately calcified, and moderately tortuous. The proximal segment showed 50-60% stenosis. The mid-segment showed 80% stenosis. Diffuse plaque buildup was noted along the entire segment (proximal to mid LAD). The lesion was classified as diffuse and segmental, moderately calcified.

IVUS was performed before intervention.

IVUS Findings and Their Impact

An IVUS catheter was advanced into the LAD. Critically, the IVUS catheter did not cross the mid-segment lesion at 80% stenosis: the severe narrowing and the moderate tortuosity prevented the IVUS catheter from passing through the culprit lesion itself. This is a documented limitation of IVUS in severely stenotic lesions and reflects the real-world experience with calcified, tortuous LAD disease 4 / Promising .

Despite this limitation, the proximal IVUS data changed the procedural plan:

• Ostial LAD: minimum lumen area (MLA) 3.7 mm2
• Mid-LAD proximal to the culprit lesion: minimum stent area (MSA) 2.5 mm2
• Plaque burden throughout the segment: greater than 60%
• Lesion characterization: calcified, fibro-fatty core

These IVUS findings established that the vessel required stent coverage from the ostium to the mid-segment, a longer segment than the angiographic appearance alone might have suggested. Without IVUS, the operator might have stented only the tightest portion of the lesion (the 80% mid-segment stenosis) and left the ostial and proximal segment undertreated. The IVUS data indicated an ostial LAD to mid-LAD stenting strategy.

The ILUMIEN ONYX trial (2,487 patients with complex coronary lesions) had demonstrated that IVUS-guided PCI produced a significantly larger minimum stent area compared to angiography-guided PCI (5.4 mm2 vs. 4.7 mm2; p < 0.001) and reduced target vessel failure at two years (7.4% vs. 10.1%; HR 0.73; 95% CI 0.57-0.93) 5 / Solid . The OCTOBER trial (1,201 patients with complex coronary lesions) showed that OCT-guided PCI reduced a composite of cardiac death, target vessel MI, or ischemia-driven target lesion revascularization compared to angiography-guided PCI 5 / Solid . These two large randomized trials, both published in 2023, established intravascular imaging guidance as the standard for complex PCI.

The Intervention

Pre-dilation was performed with a 3x15 mm TREK RX balloon at 12 atmospheres for 15 seconds. An edge dissection was noted at the distal margin of the balloon inflation, extending beyond the tightest portion of the lesion. This finding (dissection extending into a segment that was not yet stented) required stenting a longer segment than initially planned.

The first stent was a Xience Skypoint 2.50 mm x 28 mm drug-eluting stent (Abbott Vascular). The Xience stent platform is a cobalt-chromium everolimus-eluting stent with a PMA approval (P070015). The everolimus coating inhibits smooth muscle cell proliferation, which is the mechanism of in-stent restenosis 5 / Solid . Deployed at 12 atmospheres for 15 seconds in the mid to distal segment of the stenotic zone. Stent apposition confirmed visually.

The second stent was a Xience Skypoint 3.00 mm x 38 mm drug-eluting stent (Abbott Vascular). This larger diameter stent was placed from the ostial LAD through the proximal LAD, overlapping proximally with the first stent. Deployed at 12 atmospheres for 15 seconds. The overlap design (stent 2 overlapping stent 1 proximally) is standard for ostial-to-mid LAD coverage when the vessel has a step-up in caliber from distal to proximal, as is expected in a large LAD.

Post-dilation was performed with a 4.0 x 12 mm NC TREK NEO non-compliant balloon at 12 atmospheres to optimize stent expansion.

Post-Intervention IVUS

IVUS was repeated after stenting. Results:

• Proximal stented vessel: MSA 8.0 mm2 (excellent)
• Distal stented segment: MSA 4.8 mm2 (acceptable; the ACC/AHA IVUS guidance benchmark is MSA greater than or equal to 5.0 mm2 at the distal segment of a 3.0 mm stent, but 4.8 mm2 in a heavily calcified vessel in an 88-year-old patient was judged acceptable by the operator)
• Stent expansion: 100%
• Stent apposition: confirmed

Post-intervention angiography: TIMI 3 flow throughout the LAD. Zero percent residual stenosis. No dissection at the stent margins. The intervention was classified as successful.

Clopidogrel Loading

Clopidogrel 600 mg loading dose was administered orally immediately post-procedure 5 / Solid . The patient would continue clopidogrel 75 mg daily plus aspirin 81 mg daily for a minimum of six months, consistent with the 2021 ACC/AHA guideline for DAPT duration after DES implantation 5 / Solid .

Hemostasis

The radial access sheath was removed at the conclusion of the case. Hemostasis was achieved using the TR Band radial artery compression device (Terumo Corporation, Class II 510(k) device). The TR Band applies pneumatic compression to the radial access site at the wrist, allowing the patient to move her hand while hemostasis is maintained, and avoiding the immobility required for femoral manual compression. The device is deflated gradually over 90-120 minutes per the standard protocol. No complications at the access site were documented.

The patient left the cath lab at approximately 2:40 PM. Estimated blood loss: minimal.

The Evidence Behind the Decision

The clinical decisions in this case rested on several distinct evidence streams. Each is documented here.

1. CCTA + FFRct as the Diagnostic Pathway for Symptomatic CAD

The PROMISE trial (10,003 patients with stable symptoms and suspected CAD) showed that coronary CTA was non-inferior to functional testing (nuclear perfusion imaging, stress echocardiography, or exercise ECG) for the primary endpoint of death, MI, hospitalization for UA, or major procedural complication 5 / Solid . The SCOT-HEART trial (4,146 patients) showed that CCTA added to standard care reduced fatal or nonfatal MI at 5 years from 3.9% to 2.3% (HR 0.59; 95% CI 0.41-0.84) 5 / Solid . HeartFlow FFRct was evaluated in the PLATFORM trial versus conventional testing and showed non-inferior safety with fewer invasive procedures 5 / Solid . The NXT trial showed FFRct diagnostic accuracy of AUC 0.90 versus wire-based FFR as reference standard 5 / Solid .

2. FFR to Guide PCI Decision in Stable Disease

FAME (1,005 patients, stable CAD) showed that FFR-guided PCI (treating only lesions with FFR less than or equal to 0.80) compared to angiography-guided PCI reduced the primary composite of death, nonfatal MI, and urgent revascularization at 1 year (13.2% vs. 18.3%; HR 0.71; 95% CI 0.55-0.91) 5 / Solid . FAME 2 (888 patients, stable CAD with at least one FFR-positive lesion) showed that FFR-guided PCI reduced urgent revascularization compared to OMT alone (4.0% vs. 12.7% at 2 years; HR 0.32; 95% CI 0.20-0.51) 5 / Solid . These trials established the functional threshold below which PCI adds clinical benefit over OMT alone.

3. IVUS Guidance for Complex PCI

ILUMIEN ONYX (2,487 patients): IVUS-guided PCI vs. angiography-guided PCI, primary endpoint minimum stent area. IVUS guidance produced significantly larger MSA (5.4 mm2 vs. 4.7 mm2; p < 0.001) and lower target vessel failure at 2 years (7.4% vs. 10.1%; HR 0.73; 95% CI 0.57-0.93) 5 / Solid . OCTOBER (1,201 patients): OCT-guided vs. angiography-guided PCI for complex lesions. OCT guidance reduced the primary composite endpoint (HR 0.70; 95% CI 0.50-0.98) 5 / Solid . The 2023 ACC/AHA coronary revascularization guideline assigned a Class IIa (Level of Evidence B-R) recommendation to intravascular imaging guidance for complex PCI.

4. Radial vs. Femoral Access

MATRIX (8,404 patients, ACS): transradial PCI vs. transfemoral, primary outcome net adverse clinical events. Radial access reduced NACE compared to femoral (8.8% vs. 10.3%; RR 0.85; 95% CI 0.74-0.99) 5 / Solid . The reduction was driven primarily by a reduction in major bleeding (1.6% vs. 2.3%; RR 0.67; 95% CI 0.49-0.92). RIVAL (7,021 patients, ACS): radial vs. femoral, primary outcome death/MI/stroke/non-CABG major bleeding. Non-inferior overall; radial was superior in the subgroup of experienced radial operators and patients at high bleeding risk 5 / Solid 60404-2).

5. Aspirin Desensitization for Cardiac Procedures

The protocol for rapid aspirin desensitization prior to cardiac procedures is documented in Stevenson et al. (Annals of Allergy, Asthma and Immunology, 2016; 10.1016/j.aai.2016.03.027), which reported a success rate of 97.5% in 200 patients undergoing rapid desensitization before PCI, with adverse reactions in 2.5% (all successfully managed in office with antihistamines or short-acting bronchodilators). A meta-analysis by Siu et al. in JACC: Cardiovascular Interventions documented desensitization success in over 95% of patients with aspirin hypersensitivity undergoing PCI 5 / Solid . The ACC/AHA guideline on dual antiplatelet therapy recognizes aspirin desensitization as a Class IIa recommendation in aspirin-hypersensitive patients requiring DES implantation 5 / Solid .

6. PCI Outcomes in Octogenarians

PCI in octogenarians is supported by a substantial registry literature. The NCDR CathPCI registry analysis of 103,376 patients aged 80 or older showed 30-day mortality of approximately 2.1% for elective PCI, with procedural success rates similar to younger patients 5 / Solid . The ACC/AHA guideline for older adults with cardiovascular disease acknowledges that advanced age alone is not a contraindication to PCI, and that quality of life and symptom burden are appropriate drivers of the revascularization decision in elderly patients 5 / Solid . The PARTNER 3 octogenarian subgroup analysis (TAVR vs. SAVR in patients 75 years and older) documented that procedural outcomes in elderly patients are acceptable across multiple cardiac procedures when case selection is careful and when IVUS guidance is used 4 / Promising .

7. Contrast-Induced Nephropathy Prevention

Intravenous hydration with isotonic saline is the most evidence-based strategy for reducing contrast-induced nephropathy in patients with reduced GFR undergoing iodinated contrast procedures. The AMACING trial and the PRESERVE trial both addressed hydration protocols in CIN prevention 5 / Solid . Minimizing contrast volume to less than 3x GFR (mL) is a widely applied heuristic; in this patient with GFR 39, a volume of 130 mL was within this range. Acetylcysteine, formerly used for CIN prevention, was shown to be ineffective in the PRESERVE trial and is no longer recommended.

8. Dual Antiplatelet Therapy Duration After DES

The 2021 ACC/AHA DAPT guideline recommends at least 6 months of DAPT after DES implantation in patients with stable CAD (Class I, Level A) 5 / Solid . Longer duration (12 months) is recommended for patients with ACS. In this patient (elective PCI for stable CAD), 6 months of clopidogrel plus aspirin 81 mg daily was the minimum recommended duration, with an instruction to continue longer if tolerated.

The Patient’s Voice

The first thing she asked, when the cardiologist explained that she would need an aspirin desensitization procedure before the stent could be placed, was: “And if I can’t tolerate the aspirin?”

The answer was that the desensitization protocol was almost always successful for her type of reaction, and that the team had rescue medications available if she did have a reaction during the procedure.

She said: “But then I can’t get the stent.”

The cardiologist said: “Then we would discuss alternatives. But I expect you to do well with the desensitization.”

She did not say anything after that for a moment. Then she asked about the stent itself. How big was it. What it was made of. Whether it would stay in her heart forever.

The cardiologist said: yes, the stent stays in permanently. It becomes incorporated into the vessel wall. It is made of cobalt-chromium, which is a metal alloy used in many implantable devices because it is well tolerated by the body.

She asked whether she would feel it.

The cardiologist said: no. After the first few weeks, patients do not feel a coronary stent. The artery is too deep inside the chest.

She thought about this for a moment. Then she asked: “Will I be able to carry laundry again?”

That was the clinical question, translated into the terms that mattered to her. The functional goal was not an ejection fraction and not a TIMI flow grade. It was carrying laundry without stopping on the stairs.

At the April visit where the CT results were reviewed, she asked about Xanax. Her husband had been in the memory care facility for several months. She was not sleeping. She described waking at 3 or 4 AM and not being able to return to sleep. She said she had been taking naps during the day, which she had not done before. She was not tearful when she said any of this. She was matter-of-fact. The Xanax request was on her list of things she needed to address at that appointment, alongside the questions about the CT scan.

The APRN’s note documented the request and the clinical context. The anxiolytic decision was deferred pending the cardiac procedure, with a note that the sleep difficulty and anxiety in the context of a spouse with memory loss and a new significant cardiac diagnosis warranted follow-up.

During the pre-procedure assessment on the morning of the cath lab appointment, the cath lab nurse reviewed the procedure with her. The nurse documented that she verbalized understanding and agreed to proceed. No questions remained unanswered. Her ASA physical status was Class II (mild systemic disease: hypertension, mild LV dysfunction, CKD stage 3b). Consent was obtained and placed in the chart.

After the procedure, when she was in the recovery area, the RN documented that the patient was in good condition and stable. The family was updated in the waiting area at 2:39 PM.

The Family’s Role

Her daughter had driven her to the allergy clinic that morning. She sat in the waiting room while her mother underwent the desensitization protocol. She had arranged her work schedule to be available for the full day, because the plan was allergy in the morning and cath lab in the afternoon.

At the April appointment where the CT results were reviewed, the daughter was present. The APRN’s note documented: patient is accompanied by her daughter today. The daughter asked clarifying questions about the procedure (whether it was open-heart surgery, the answer being no; whether her mother would need general anesthesia, the answer being no, moderate sedation; whether she would be hospitalized overnight, the answer being the plan was same-day discharge if the procedure was uncomplicated).

The daughter was also present for the Xanax conversation. She supported the request. She described what her mother’s daily situation looked like: driving herself to appointments, managing the logistics of the memory care facility visits, and dealing with the financial and administrative complexity of being the spouse of a man who could no longer manage his own affairs. “She does all of that alone,” the daughter said. The APRN heard this and noted it.

The family update at 2:39 PM, after the procedure was complete, was delivered by the cath lab procedure nurse. Final disposition of patient: discharged to home in good and stable condition.

The cardiac rehab Phase 2 referral was placed at 2:43 PM by the interventional cardiologist. The order specified: cardiac rehab location, Danville; reason for referral, CAD/Stent. Release to patient: immediate. The rehab program was within driving distance of where she lived. Her daughter would take her to the first session.

The Outcome

She was discharged from the hospital the same day, in the early evening, approximately four hours after the procedure ended.

Immediate Outcome

The procedure was technically successful by all standard metrics: TIMI 3 flow through the stented LAD, zero percent residual stenosis, no stent dissection at the margins, no hemodynamic instability during or after the procedure, no access site complication. The Syntax score was less than 22. No complications were documented.

She tolerated the aspirin desensitization without adverse reaction. She was instructed to take aspirin 81 mg daily starting the following morning, with an explicit warning: any interruption in aspirin of more than 48 hours would require repeat desensitization before the drug could be resumed safely. This instruction matters because stent thrombosis risk, while declining over time, remains highest in the first month after stent implantation, and the aspirin tolerance achieved through desensitization is maintained only by continuous dosing 5 / Solid .

The RCA stenosis (70% by angiography, FFRct 0.82) was not addressed at this procedure. The clinical team documented: consider staged PCI to RCA if clinically indicated. The RCA lesion, while anatomically significant, was not hemodynamically significant by the FFRct threshold. The decision to defer it was appropriate and consistent with current guidelines.

Short-Term Follow-Up (Expected)

For a patient of this clinical profile, the expected short-term trajectory, based on published outcome data, includes:

Creatinine: a transient increase in creatinine by 0.3-0.5 mg/dL within 48-72 hours of the procedure is expected in approximately 20-25% of patients with baseline GFR below 45 who receive greater than 100 mL of iodinated contrast, returning to baseline within 7-14 days in most cases 5 / Solid . A creatinine check at 48-72 hours post-procedure is standard practice.

Cardiac rehabilitation: Phase 2 cardiac rehab was ordered same-day. Published data from the NACR and the Cochrane systematic review on cardiac rehab after revascularization document reductions in cardiovascular mortality (risk ratio approximately 0.74; 95% CI 0.64-0.86) and hospital readmission in patients who complete Phase 2 cardiac rehab 5 / Solid . For an 88-year-old woman, the specific goals of cardiac rehab are modified: the primary endpoint is functional capacity and quality of life (ability to carry laundry, ability to climb stairs without symptoms) rather than maximal VO2 improvement.

DAPT adherence: the clinical team’s explicit instruction was 6 months minimum of dual antiplatelet therapy. Discontinuation of DAPT in the first year after DES implantation substantially increases the risk of stent thrombosis, and early discontinuation (first 30 days) carries the highest risk. Adherence counseling and clear patient instruction are the most effective interventions for DAPT discontinuation prevention 5 / Solid .

What This Case Did Not Resolve

The case addressed the hemodynamically significant LAD stenosis. It did not address:

1. The RCA moderate disease (70% stenosis, FFRct 0.82): this requires reassessment after recovery. If symptoms persist after LAD revascularization, the RCA lesion may require further evaluation with wire-based FFR at the time of a staged procedure.

2. The mild LV systolic dysfunction (EF 45-50%): regional wall motion abnormalities in the LAD territory may partially recover after successful revascularization of the culprit lesion, a phenomenon known as hibernating myocardium 4 / Promising . A repeat echocardiogram at 3-6 months post-procedure would assess EF recovery.

3. The sleep difficulty and situational anxiety: the cardiac procedure does not change the life circumstances that produced the Xanax request. Follow-up for this was explicitly planned.

4. The aspirin allergy maintenance: the patient’s long-term aspirin tolerance depends on uninterrupted daily dosing. Any surgical procedure, gastrointestinal illness, or new prescription that interrupts aspirin requires coordination with the allergy team.

The outcome of this case was good. The procedure was uncomplicated, the stent was placed successfully, and the patient was discharged home the same day. The honest statement of prognosis, based on published registry data for octogenarians undergoing elective PCI, is a 30-day MACE rate of approximately 2-4% and a 1-year MACE rate of approximately 8-12% 5 / Solid . These are not trivial numbers. They are the numbers that belong in the shared decision-making conversation, and they are the numbers that put the patient’s question about carrying laundry in its clinical context: a successful procedure is the most likely outcome, and the functional benefit is likely to be real, but the long-term prognosis reflects the underlying severity of the disease, not just the technical success of the procedure.

What This Case Teaches

Primary Teaching Point

In octogenarian patients with aspirin hypersensitivity and FFRct-confirmed hemodynamically significant LAD stenosis, same-day aspirin desensitization followed by IVUS-guided PCI is safe, feasible, and supported by published protocol data and the ILUMIEN ONYX evidence base, provided that the allergy/immunology team and the interventional cardiology team coordinate the sequencing explicitly on the day of the planned procedure.

The reasoning: aspirin hypersensitivity is not a contraindication to PCI in the presence of a drug-eluting stent indication. The contraindication is not aspirin allergy per se; it is the inability to receive DAPT. Rapid desensitization protocols overcome that barrier in more than 95% of patients with non-AERD, non-CIU aspirin hypersensitivity. The desensitization must be performed the same day as the procedure, because tolerance is established acutely and maintained only by continued dosing. A desensitization performed the week before and then interrupted would require repeat desensitization.

The clinical consequence of not applying this reasoning: deferral of PCI for a functionally significant LAD lesion in an 88-year-old woman with symptomatic exertional ischemia, on the grounds that she is allergic to aspirin. Deferral leaves the lesion untreated. The FAME 2 data show that an FFR-positive lesion treated with OMT alone (rather than PCI) carries a substantially higher rate of urgent revascularization events over subsequent years 5 / Solid . Deferral is not benign. The aspirin allergy barrier can be removed; the lesion cannot be left alone without consequence.

Secondary Teaching Points

1. IVUS guidance for calcified, complex LAD disease is the evidence-based standard. The ILUMIEN ONYX and OCTOBER trials establish intravascular imaging guidance for complex PCI as a Class IIa recommendation. In a calcified, diffusely diseased LAD with an 80% mid-segment stenosis and a risk of stent malapposition, IVUS guidance changed the procedural plan in this case: the IVUS data established that the stenting strategy should begin at the LAD ostium, not only the most stenotic segment. Without IVUS, this ostial extent might have been underappreciated.

2. Radial access reduces bleeding risk in elderly patients. The MATRIX trial data support the radial access choice in an elderly woman with multiple comorbidities. The TR Band radial compression device further simplifies post-procedure hemostasis in a patient who cannot lie still on a stretcher for the 4-6 hours required for femoral manual compression.

3. FFRct below 0.80 in the presence of visual severe stenosis on CCTA justifies proceeding directly to invasive evaluation. The NXT trial, PLATFORM trial, and related data establish FFRct as a non-invasive functional test that distinguishes hemodynamically significant stenoses from anatomically severe but functionally non-significant lesions. An FFRct of 0.68 in a symptomatic elderly patient with regional wall motion abnormalities on echo and exertional symptoms is the functional justification for the invasive management approach.

4. Same-day cardiac rehabilitation initiation is a quality metric, not an afterthought. The cardiac rehab Phase 2 order placed at 2:43 PM, the same afternoon as the procedure, is a documented component of complete post-PCI care. The published evidence on cardiac rehab participation rates shows that patients who receive the order at the time of the procedure are significantly more likely to enroll than patients who receive it at a subsequent outpatient visit.

5. The whole-person dimension of a cardiac case includes the circumstances that produced the patient’s anxiety. The Xanax request was not a distraction from the cardiology work. It was clinical information: an 88-year-old woman managing a cardiac procedure and a spouse with advancing dementia, alone, without adequate sleep, was carrying a comorbid burden that had not yet been addressed. The note placed in the chart at the April visit documented this. The follow-up was planned. The coronary procedure addressed one layer of the clinical picture. The other layer required a different kind of attention.

Clinical Synthesis

12.1 Paired Foundations Articles

Cardiac Catheterization This case demonstrated the left heart catheterization and coronary angiography procedure in a real-world context: why it is performed after non-invasive imaging rather than as the first test, what the catheter findings add to the CT findings, and what happens in the room when the procedure is underway. The Foundations article explains the catheterization procedure from first principles: what the catheter is, how access is obtained, what the pressures measured tell the cardiologist about the heart’s function, and what the angiography images show that CT cannot.

Coronary Stenting This case described the specific stent chosen (Xience Skypoint, cobalt-chromium everolimus-eluting), the rationale for stent sizing (driven by IVUS rather than angiographic estimation), and the deployment sequence. The Foundations article explains what a drug-eluting stent is, how the everolimus coating prevents restenosis, what the XIENCE V SPIRIT trial data showed about long-term outcomes, and what the patient needs to know about stent thrombosis risk and DAPT adherence.

Intravascular Ultrasound (IVUS) This case showed IVUS guidance changing the procedural plan: the inability of the IVUS catheter to cross the culprit lesion, the proximal MLA of 3.7 mm2 indicating the need for ostial coverage, and the post-stent MSA confirming adequate expansion. The Foundations article explains what IVUS is, how the imaging catheter works, what it shows that angiography cannot (plaque burden, calcium depth, stent expansion, stent apposition), and why the ILUMIEN ONYX trial changed the field.

Coronary Plaque: What It Is and Why It Matters The calcium score of 505 in this patient reflected a lifetime of coronary plaque accumulation, with the LAD bearing two-thirds of the total calcium burden. The Foundations article explains the biology of atherosclerotic plaque, the difference between calcified, fibrous, and lipid-rich plaque, why soft plaque (lipid-rich core with thin fibrous cap) is more dangerous than calcified plaque despite appearing less severe on angiography, and how plaque characterization by CCTA or IVUS changes clinical decision-making.

Heart Failure with Mildly Reduced Ejection Fraction (HFmrEF) This patient had an EF of 45-50 percent, placing her in the HFmrEF range (EF 41-49% by current ACC/AHA classification). The regional wall motion abnormalities and increased filling pressures documented on echocardiography reflected the downstream consequence of chronic LAD territory ischemia. The Foundations article explains the HFmrEF classification, the guideline-directed medical therapy evidence for this group (which is less well-established than for HFrEF and HFpEF), and the potential for EF recovery with successful revascularization of ischemic but viable myocardium.

12.2 Offer Routing

If you have been told that a coronary stent may be needed, and you are working through the information about what that means and what happens next, a structured cardiovascular assessment is a structured framework for reviewing the clinical picture before the cath lab date. It does not replace the interventional cardiologist. It prepares you for the conversation: what questions to ask, what the imaging results mean in plain language, and what the evidence says about your specific clinical situation. A structured cardiovascular assessment is available at any stage of the workup, from the first CCTA result to the post-procedure recovery period.

If you or someone you care for has already had a stent placed and is now in the post-procedure phase, structured remote monitoring provides ongoing monitoring and clinical engagement: DAPT adherence tracking, cardiac rehabilitation participation support, and follow-up assessment of LV function and residual disease at the appropriate time intervals.

Both programs are available through Carle Foundation Hospital’s Heart and Vascular Institute at its Urbana location (611 West Park Street, Urbana, IL 61801; 217-904-7000) and at the Danville Riverfront cardiology office (516 West Madison Street, Danville, IL 61832; 217-554-1700). Patients in rural central Illinois requiring IVUS-capable interventional cardiology are served by Carle Foundation Hospital in Urbana and by Methodist Medical Center in Peoria.

The cardiologist who stood in that cath lab understood what was at stake: an 88-year-old woman who wanted to carry her own laundry. The stent was the technical part. The rest of the work, the rehabilitation, the medication adherence, the sleep, the husband in the memory care facility, all of it continues after the stent is placed. This programs are designed for that continuation.

The Signal Check is fifteen questions mapping the cardiovascular risk pattern across the physiological domains most commonly missed in standard screenings. It produces a specific starting point for your next clinical conversation.