Clinical introduction A man in his early 30s with remote history of a febrile rash as a toddler presented to the emergency room following an out-of-hospital cardiac arrest while riding his bicycle. He received bystander cardiopulmonary resuscitation and one shock from an automatic external defibrillator, successfully restoring sinus rhythm. On arrival, he was haemodynamically stable without ECG evidence of ST segment changes to suggest active ischaemia, and an initial troponin I was mildly elevated at 0.10 ng/mL (normal <0.04 ng/mL). A CT angiogram (CTA) was obtained showing a normal-appearing aorta and no abnormal extracardiac findings. Urgent coronary angiography was performed; images are shown in figure 1A–C. Echocardiogram revealed a mildly reduced left ventricular ejection fraction (45%) with a hypokinetic inferior wall.

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Figure 1

(A) Right coronary artery angiogram in the left anterior oblique cranial projection. (B) Left coronary artery angiogram in the right anterior oblique caudal projection. (C) Left coronary artery angiogram in the right anterior oblique cranial projection. CAUD, caudal; CRAN, cranial; LAO, left anterior oblique; RAO, right anterior oblique.

Question What is the next best step in the management of this patient at this time?

1. Complete revascularisation via percutaneous coronary intervention (PCI).

2. Referral for coronary artery bypass surgery (CABG).

3. Initiation of high-dose steroids.

4. Initiation of dual-antiplatelet therapy without planned revascularisation.