34 years male, athlete byprofession, with complaints ofTypical chest pain x 2 days backNo h/o Exertional breathlessness,effort anginaNo ECG changes except small q inlead IIIECHO – No RWMA, EF ~ 60%Trop I – PositiveNo h/oHTN/DM/DLP/CAD/CKD/CVA/tobacco/alcohol/Drug abuse•       Verystrong family h/o CAD•       Father/Mother/Grandmother/Grandfather– all died of CAD•       Onlyfamily member alive is his sister 

•       Allblood work was normal except•       Hb– 16.5 mg/dl•       TropI – 256ng/ml (strong positive)•       Patientwas advised CAG but refused (even CT-CAG) – he was depressed and devastatedafter multiple tragedies in family•       Patientwas counselled and advised treatment•        •       Nextday patient came to OPD to get the CAG done•       Admittedand taken up for CAG

Before doing PTCA ?•       Patientis national athlete•       Isthe patient symptomatic?•       Howis the intervention going to benefit the patient?•       Canthe intervention affect the patient’s carrier?•       Canintervention be harmful to the patient?•       Doyou have exertional breathlessness or exertional chest pain or heaviness?•       “Iam a national athlete sir. No symptoms at all. Today I ran for 20km beforecoming here and I was absolutely fine”.•       Haveyou ever experienced any symptoms before this during exercise?•       “Sirthis is my warm-up. I usually run 100km on the training days.”•       Immediatelydecided to not do an intervention – •       optedfor physiological assessment with iFR.What else should have been done?•       IVUSshould have been done to assess the plaque morphology – but was not done due tofinancial constraints.•       Geneticstudies for hereditary atherosclerotic coronary artery disease should be done. •       Optionsif iFR turn out positive•       Evenif iFR would have been positive – •       Imagingis a very good tool in such cases and should be done.•       StentlessPCI i/v/o strong family history - as these patients can have aggressive disease•       Instead,DEB is very good option•       EvenOMT with lifestyle management is also very good option for risk reduction insuch patients.•       Aggressivelipid lowering treatment is must.•       Plaquescan be followed up on CT – CAG to know about the progression.•         

•       Benefitof intervention has to be weighed in every patient.•       Holisticapproach of treatment benefit and patient profile should be taken.•       Thedecision for defer or prefer should have strong argument in every case.•       Physiologicalassessment is a strong tool to support the decision during an intervention.•