DR. ZAHOOR

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A 50 year old man presents to clinic with a complaint of central chest discomfort of 2 weeks’ duration, occurring after walking for more than 5 minutes or climbing more than 1 flight of stairs. The chest discomfort resolves with rest within several minutes. He is obese, has a history of hypertension, and smokes 10 cigarettes a day. His father died from a myocardial infarction at the age of 54 years.

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On examination, his blood pressure is 144/92 mmHg with a heart rate of 82bpm. The remainder of his examination is normal.

Questions What is the diagnosis? Stable angina What two advise you will give to patient? 1- stop smoking 2-mange his weight

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• A 60 year old man with a history of a myocardial infarction presents to clinic for follow up. He was started on aspirin, beta blocker, and statin therapy after his heart attack. In the past 2 weeks the patient has noted return of chest pressure when he walks rapidly. The chest pressures resolves with sublingual glyceryl trinitrate or a decrease in his activity level. He is a former smoker and has modified his diet and activity to achieve his goal body weight.

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He is normotensive on examination with a heart rate of 72 bpm. The remainder of his examination is normal.

Questions• What is the diagnosis?• Stable angina• What first investigation you will do? • ECG• If ECG is normal, what will be your next

investigation? Exercise stress test

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John is a 64 year old male new to the area who presents to the surgery. John reports that he has a history of hypertension (20 years) and angina (2 years). He was a heavy smoker, 30 per day for 48 years, but ceased 9 months ago. He has no history of gastrointestinal bleeding and nil known allergies.

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A letter from his previous GP reports that John has a non ST segment elevation myocardial infarction (NSTEMI) 12 months ago for which he underwent a percutaneous transluminal coronary angioplasty and stent to his left coronary artery. John was involved in a cardiac rehabilitation program at the local hospital for six weeks after his discharge. Since then he walks briskly for 40 minutes every day and describes no angina.

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Current medications: aspirin 100mg daily, clopidogrel (Iscover, Plavix) 75mg daily, perindopril (Coversy) 4mg daily, simvastatin (Lipex, Simar, Zocor) 20mg daily. Further discussion identifies John’s lack of understanding of the purpose of his medicines and he admits to not always being complaint.

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On examination his blood pressure is 145/85mmHg, pulse rate 80 per minute regular and his chest is clear on auscultation. Echocardiogram six months ago showed no evidence of heart failure. Body mass index is 23.5 kg/m2.

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Blood results taken six weeks ago were mostly normal but you note a total cholesterol of 5.5 mmol/L, low density lipoprotein (LDL) cholesterol 3.9 mmol/L, high density lipoprotein (HDL) cholesterol 0.8 mmol/L and triglycerides 1.8mmol/L.

Questions• What is acute coronary syndrome?• 1-unstable angina 2-nstemi 3-stemi• Will you do exercise test in a patient with

NSTEMI? no

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• A very physically active 49 year old male with a history of labile hypertension and hypercholesterolemia with an LDL cholesterol of 126 mg%. He underwent an exercise stress test which revealed reversible inferoseptal ischemia at a peak heart rate of 171 bpm and peak blood pressure of 195/85. In the expert’s opinion, the results suggest that the patient has silent myocardial ischemia and may be at risk for sudden cardiac death, especially in light of the marked exertional level of activity.

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The expert suggests additional testing in order to conform or exclude a coronary artery obstruction, and to determine the right medical therapy and/or intervention. In the meantime, he suggests a reduction in physical activity.

Questions• What is the diagnosis? IHD• What are the risk factors present in this

patient?• hypertension and hypercholesterolemia• What will be your next investigation? • PCI

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