Break Away From the Hemodynamic “Gray Zone”

We present a case of a 35-year-old man with no prior history of hypertension or diabetes who was admitted with non-ST-elevation acute coronary syndrome. The patient was hemodynamically stable, and his Global Registry of Acute Coronary Events score indicated a low risk of in-hospital mortality. The culprit distal left circumflex artery/third obtuse marginal branch lesion was successfully treated with drug-coated balloons. The nonculprit left anterior descending artery lesion had a fractional flow reserve measured as 0.76, in the hemodynamic "gray zone". A shared decision with the patient was made to defer intervention and instead commence intensive optimal medical therapy including dual antiplatelet therapy, a beta-blocker, and intensive lipid-lowering therapy with atorvastatin and evolocumab. At the 3-month follow-up, the patient reported complete relief of chest tightness, with a 73.6% reduction in his low-density lipoprotein cholesterol, accompanied by remarkable plaque regression, stabilization, and functional improvement.