20 cases spanning antianginal, antiplatelet, and revascularization-strategy decisions in stable and acute coronary disease.
The occlusion is real and his symptoms are real, but his mild symptom burden, preserved EF, and reduced kidney function all point toward asking how far medical therapy can go before reaching for the procedure.
She has never had a symptom in twelve years of diabetes, and the ischemia on her stress test was found only because her knee surgery required testing that wasn't looking for it.
The angiogram alone can't say whether this lesion is actually causing his symptoms — and he's made clear he doesn't want to leave with an answer that sounds like wait and see.
She's eighteen months out from an uncomplicated MI with a normal ejection fraction, and the newest trial evidence on long-term beta-blocker use doesn't clearly say she has to keep taking it.
His culprit lesion is already treated — the open question is a significant second lesion, and whether his kidneys can tolerate finishing the job today or need a day or two first.
A single patient whose coronary anatomy is genuinely revascularizable by either approach, which is exactly what turns this into a real decision rather than an anatomic foregone conclusion. The disagreement is about which five-year tradeoff — death and MI risk against an early excess of stroke — she should be the one to choose.
A single patient whose SYNTAX score sits precisely where two major trials asked the same question and reached different answers. The disagreement isn't settled by more data — it's handed, deliberately, back to the patient himself.
A single patient whose coronary arteries are clean, which used to be where a workup like hers ended rather than where it actually began. The disagreement is about whether to test for the mechanism first or treat the most likely one directly.
A single patient whose admission LDL leaves little doubt he needs aggressive lipid-lowering. The disagreement is about whether a second drug starts today alongside the first, or only after a follow-up lab proves the first one wasn't enough.
A single patient who now needs both an anticoagulant and an antiplatelet regimen, and both teams agree on that much immediately. What isn't agreed is how many days of overlap her fresh stent actually needs before the third drug comes off.
A single patient whose angina, and whose chart, both lack the one detail that used to make his first prescription an obvious choice. The disagreement is about whether a decades-old default deserves to keep making that choice for him.
A single patient whose symptoms are manageable enough that either path — a procedure or a better medication regimen — could plausibly be called sufficient. The disagreement is about which one gets tried, and proven, first.
A single patient bound for the cardiac catheterization lab within the day, and a drug that could start now or wait until his anatomy is actually known. The disagreement is about which timing the trial evidence actually supports.
A single patient already on the table for an emergent stent, and an anticoagulant decision the team is finalizing in the same minutes as the procedure itself. The disagreement is about how much the original bleeding-advantage data still apply now that the access route itself has changed.
A single patient, one month out from her first stent, asking a direct question about a side effect she's already noticing. The disagreement is about whether the answer is a full year on the stronger drug regardless, or a test that could shorten that timeline honestly.
A single patient whose artery is torn, not blocked by plaque, which changes what "fixing it" is even likely to mean. The disagreement is about whether a stent helps a vessel like this or extends the very tear it's meant to repair.
A single patient for whom the standard next step after a heart attack assumes a level of mobility she doesn't have. The disagreement is about whether that standard step still deserves to be pursued, or whether the same effort belongs somewhere else entirely.
A single patient whose stenting was complex enough to argue for a full year of dual therapy, and whose lab work argues just as directly for stopping one drug early. The disagreement is about which risk actually carries more weight for him specifically.
A maximized calcium-channel blocker has only partly controlled her coronary spasm, and the best-suited second-line drug for her situation isn't available in the country she lives in. The disagreement is about what to add instead.
The same segment of his left anterior descending artery has narrowed a second time, inside two layers of stent already. The disagreement is about whether the next step should be another procedure or a harder look at why this segment keeps narrowing in the first place.