The n e w e ng l a n d j o u r na l of m e dic i n e

Images in Clinical Medicine

Chana A. Sacks, M.D., Editor

Regression of Coronary Atherosclerosis

with Medical Therapy
A Before Therapy, Moderate Ischemia on Perfusion Imaging B Severe Stenosis on Coronary CTA
Stress

Rest

C After Therapy, No Visible Ischemia D Reduction in Plaque on Coronary CTA

Stress

Rest

Abhishek Keraliya, M.D.
Ron Blankstein, M.D.
Brigham and Womens Hospital
Boston, MA
rblankstein@bwh.harvard.edu
A
42-year-old man with hyperlipidemia and a family history of coro-
nary artery disease presented with a 4-month history of intermittent exertional
chest pain. Myocardial perfusion imaging performed during exercise showed
moderate ischemia in the distribution of the left circumflex coronary artery (Panel A,
arrow). Coronary computed tomographic angiography (CTA) revealed a large amount of
atherosclerotic plaque in the proximal left circumflex coronary artery, which had resulted
in severe stenosis (Panel B, arrow). The patient was treated for chronic stable angina with
high-intensity statin therapy, ezetimibe, a beta-blocker, and aspirin; he was advised to
adopt a healthy diet and to engage in regular physical activity. Over time his symptoms
resolved. Four years later, he reported the onset of atypical chest pain. Repeat myocar-
dial perfusion imaging showed no myocardial ischemia (Panel C, arrow), and repeat coro-
nary CTA showed a marked reduction in the amount of plaque and the severity of stenosis
in the left circumflex coronary artery (Panel D, arrow). The CTA results were reassuring
that his current symptoms were not cardiac. These imaging findings suggest that even
when severe stenosis is present, coronary artery disease can regress with medical therapy.
DOI: 10.1056/NEJMicm1609054
Copyright 2017 Massachusetts Medical Society.

1370 n engl j med 376;14 nejm.org April 6, 2017

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