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Abstract: Obsolete myocardial infarction is caused by poor lifestyle habits. This patient came to the clinic due to paroxysmal chest tightness and chest pain for more than half a month, aggravated for 1 day. It was indicated that he had undergone coronary stenting for acute myocardial infarction and his symptoms were well controlled after the operation, but he had a past history of hypertension and smoking, and he did not take oral medication regularly after the operation, so he was diagnosed with old myocardial infarction after the consultation. He was diagnosed with old myocardial infarction after consultation. After drug treatment, his condition was controlled and his symptoms improved significantly.
Basic information】Male, 50 years old
Type of disease】Old myocardial infarction
Hospital】Harbin First Hospital
Date of consultation】May 2022
Treatment plan】Medication (aspirin enteric solution tablet + clopidogrel hydrogen sulfate tablet + risuvastatin calcium tablet + iloyumab injection + metoprolol succinate extended release tablet + isosorbide mononitrate tablet + sakubatril valsartan tablet)
Treatment period】7 days of inpatient treatment, 1 month of outpatient follow-up
Treatment effect] The disease was controlled and the chest pain disappeared.
I. Initial consultation
Through detailed communication, we learned that the patient had undergone coronary stent implantation for acute myocardial infarction in October 2021 and was a patient with old myocardial infarction, who had not taken the relevant oral secondary prevention drugs regularly recently. In the past half month, he was prone to chest pain after emotional stress or exertion, and his symptoms were relieved after sitting down and resting or taking nitroglycerin under the tongue. The patient had a history of myocardial infarction, hypertension and smoking, and he did not take oral medication regularly after the infarction, so we cannot exclude the possibility of intra-stent thrombosis or other serious vascular lesions.
II. Treatment history
The patient was advised to review coronary angiography to help clarify the diagnosis. The coronary angiography showed 50% stenosis of the first diagonal branch and 50% stenosis of the middle and distal segments of the gyral branch, while the rest of the vessels did not show significant stenosis. Based on the findings, the patient did not require stenting and needed intensive drug therapy. The patient was then instructed to continue dual antiplatelet therapy, i.e. aspirin enteric coated tablets and clopidogrel hydrogen sulfate tablets for intensive lipid-lowering therapy, and it was recommended to lower LDL to below 1.4 mmol/L, combined with subcutaneous injection of elosumab injection on top of resulvastatin calcium tablets. In addition, patients are advised to take oral metoprolol succinate extended-release tablets to control the ventricular rate and improve myocardial ischemia, and to control the heart rate to 55-60 beats/minute as much as possible. Oral isosorbide mononitrate tablets to dilate blood vessels and improve myocardial ischemia. Oral sakubatril valsartan tablets were given to lower blood pressure as well as prevent heart failure. And the patients were told to combine lifestyle interventions to improve, low salt and low fat diet, and pay attention to balanced dietary nutrition.
III. Treatment effect
After 7 days of treatment with the optimized therapeutic drug regimen, the patient’s self-perceived symptoms improved significantly, and the heart rate could be basically controlled at about 60 beats/min, and the blood pressure could be controlled below 130/80 mmHg; the symptoms of chest tightness and chest pain basically did not occur with moderate intensity exercise. The electrocardiogram was repeated, and the myocardial ischemia was significantly improved compared with before, and the patient was discharged. The patient was instructed to pay attention to the 1-month outpatient follow-up.
IV. Notes
We are glad that the patient’s symptoms have been relieved. We should pay attention to monitoring blood pressure and heart rate on weekdays, and come to the hospital every six months for physical examination and review, such as cardiac ultrasound, blood routine, urine routine, liver function, kidney function, blood lipids, homocysteine, serum uric acid, and electrocardiogram. In particular, LDL should be strictly controlled to meet the standard, below 1.4 mmol/L if possible. Patients are advised to pay attention to regular monitoring of blood pressure and heart rate, and must take relevant oral medications to improve their prognosis on time and seek medical attention if they are unwell.
V. Personal insight
From this case, we know that for patients with old myocardial infarction, stent implantation does not mean that the disease is cured, and the stent is installed to improve the patient’s prognosis and prevent sudden death, and the follow-up medication is crucial. In addition, patients with old myocardial infarction should also combine lifestyle interventions to improve them and pay attention to regular follow-up medical examinations. Treatment of old myocardial infarction should be lifelong and should not be stopped at will.