(Disclaimer: This article is for scientific use only, and the relevant information in the following content has been processed to protect patient privacy)
Abstract: In the past 1 week, the patient had recurrent paroxysmal chest tightness with no obvious cause. Through the patient’s symptoms and electrocardiographic performance, the patient was diagnosed with severe coronary vascular stenosis, including coronary artery disease and left bundle branch block. As the patient refused further coronary interventional treatment, only intensive medication was recommended. After systematic treatment the patient’s symptoms were significantly relieved, but the risk was still extremely high, and coronary interventional treatment was recommended as soon as possible and as soon as possible.
Basic information】Female, 63 years old
Disease Type】Coronary heart disease, left bundle branch block, hypertension, diabetes mellitus
Hospital】Harbin First Hospital
Date of Consultation】June 2022
Treatment plan】Medication (low molecular weight heparin calcium injection, isosorbide nitrate injection, Danhong injection, sodium phosphate for injection, bisoprolol fumarate tablets, perindopril indapamide tablets, sakubatril valsartan sodium tablets, aspirin tablets, clopidogrel hydrogen sulfate tablets, resuprastatin calcium tablets, ezetimibe tablets, isosorbide mononitrate tablets)
Treatment period】7 days of inpatient treatment and regular outpatient follow up
Treatment effect】The symptoms of chest tightness are basically relieved and disappeared, but there is still chest tightness after emotional excitement or after exertion.
I. Initial consultation
I was on duty in the ward today, and a patient came to the hospital with a hospitalization order and no family member. The patient told me that he had been experiencing chest tightness for about 3 minutes each time in the past week, and the chest tightness worsened especially after activity or when he was emotionally agitated. He was diagnosed with hypertension and diabetes about 10 years ago, and was able to take regular oral medications such as bisoprolol fumarate tablets, metformin hydrochloride tablets, resulvastatin calcium tablets, and perindopril indapamide tablets at home on a regular basis. Despite taking the medications, there was no regular monitoring of blood glucose as well as blood pressure. After settling the patient, the patient was placed in bed and an electrocardiogram was performed. The electrocardiogram showed: sinus rhythm; complete left bundle branch block with ST-T changes. Blood pressure and heart rate blood pressure were measured. Blood pressure: 140/85 mmHg, heart rate: 85 beats/min. Preliminary diagnosis: coronary artery disease, left bundle branch block, hypertension, and diabetes mellitus.
II. Treatment history
I first gave the patient subcutaneous injection of low-molecular-weight heparin calcium injection, intravenous pumping of isosorbide nitrate injection, adjuvant sedation of danghong injection and sodium phosphocreatine for injection. In combination with the patient’s symptoms and the presence of left bundle branch block on the electrocardiogram, an urgent infarct triple test was performed to further clarify whether acute myocardial infarction had occurred. The infarct triplet was negative and the ECG was repeated again without dynamic changes, which could exclude the possibility of acute myocardial infarction. Adjust the oral dose of bisoprolol fumarate tablets to control the patient’s heart rate to 55-60 beats/min if possible. Replace the antihypertensive drug perindopril indapamide tablets with sakubatril valsartan sodium tablets, and control the patient’s blood pressure below 130/80 mmHg as much as possible, and gradually adjust the dose until the ideal value is reached according to the patient’s blood pressure after taking the drug.
In the process of medication treatment, we gradually improve the examination, and consult with the patient to perform coronary angiography to clarify whether there is serious stenosis of coronary vessels, because the patient is a woman living alone without any relatives, she cannot receive surgical examination and treatment. The coronary CT showed severe stenosis of the left anterior descending branch mixed plaque lumen, severe stenosis of the left main trunk mixed plaque lumen, and severe stenosis of the right coronary artery mixed plaque lumen. Based on the examination results, the patient was again recommended to undergo coronary intervention, but the patient still refused. The patient was instructed to take dual antiplatelet, combined with oral clopidogrel hydrogen sulfate tablets on top of aspirin tablets, and was advised to take oral ezetimibe tablets on top of rasulvastatin calcium tablets based on the LDL laboratory results. The patient’s symptoms improved significantly in about 3 days of systematic medication, and the pumping of isosorbide nitrate injection was stopped and changed to oral isosorbide mononitrate tablets, and he was discharged after 7 days of hospitalization.
III. Treatment effect
After the systematic medication, the patient’s chest tightness could be relieved and disappeared basically. After all, the patient’s coronary vascular problem with severe stenosis was not solved, so he still tended to have chest tightness when he was emotionally excited or when he was exercising. The patient’s blood pressure was basically controlled below 130/80 mmHg, heart rate was basically controlled at about 60 beats/min, and all other indexes were also improved, and the patient was instructed to come to the outpatient clinic for regular review.
IV. Notes
We are glad that the patient’s symptoms improved after treatment, but we still remind the patient to pay attention to regular monitoring of heart rate, blood pressure and blood glucose after discharge, and to keep them within the ideal range to help prevent the occurrence of acute myocardial infarction. It is important to eat a low-salt, low-fat, low-sugar diet, eat more fresh fruits and vegetables, eat seven minutes of each meal, and increase the intake of whole grains. If the patient is unable to control LDL below 1.4 mmol/L on top of taking oral resulvastatin calcium tablets and ezetimibe tablets, subcutaneous injection of elosumab is recommended. The patient’s condition is severe, and he is recommended to come to the hospital every 3-6 months for a review of the relevant physical examination, and he is also recommended to undergo coronary intervention as soon as possible. During the course of taking medication, attention should also be paid to observe any bleeding tendency.
V. Personal insight
In clinical practice, if you encounter a patient with chest tightness or chest pain and left bundle branch conduction block on electrocardiogram, you must be highly alert to the occurrence of acute myocardial infarction, and after excluding acute myocardial infarction, you should further consider the presence of other serious organic pathologies, such as the presence of hypertensive heart disease and serious stenosis of coronary vessels. Coronary angiography or coronary CT was suggested. The patient proved to have serious coronary vascular lesions. Due to the patient’s special condition, he could not receive coronary intervention, and if he chose conservative drug treatment, he should be monitored closely for independent risk factors of atherosclerotic disease such as homocysteine, serum uric acid, blood pressure, blood lipids and blood sugar. Regular oral administration of relevant secondary prevention medications, especially aspirin tablets and Rosuvastatin calcium tablets, is of utmost importance.