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Abstract: A 62-year-old patient with cardiovascular disease was diagnosed with coronary artery disease, the main cause of chronic ischemic heart disease, at a local hospital 1 year ago because of chest tightness and chest pain, and therefore underwent stenting treatment, and her symptoms improved at that time. However, in the last 2 months, he occasionally felt chest pain similar to the symptoms before the surgery and came to the hospital. After a series of tests, the patient was diagnosed with in-stent restenosis and was given surgical treatment and medication.
Basic information】Male, 62 years old
Disease Type】Chronic ischemic heart disease
Hospital】Wuhan University People’s Hospital
Date of consultation】May 2022
Treatment plan】Surgical treatment (coronary artery stenting, drug balloon dilatation molding) + oral medication (aspirin tablets, Tegretol tablets, Rosuvastatin calcium tablets, Metoprolol succinate extended-release tablets, Sacubitril valsartan sodium tablets) + subcutaneous injection (Elojuvumab injection)
[Treatment period] 6 days of inpatient treatment, 1 month of outpatient follow-up
Treatment effect】The patient’s condition was stable and no recurrence of chest pain.
I. Initial consultation
He was diagnosed with hypertension and diabetes mellitus many years ago. He was diagnosed with coronary heart disease at the local hospital 1 year ago because of chest tightness and chest pain, and underwent stenting treatment, after which his symptoms improved significantly. In the last 2 months, I occasionally felt chest pain, which was not very obvious in relation to the activity, but the symptoms were more like those before stenting, with colic feeling, which lasted about 10 minutes each time before getting better. So, the CTA of the concerned coronary artery was reviewed at the local hospital, suggesting mild stenosis of the left anterior descending branch and gyral branch, and after right coronary stenting, stenosis of the proximal segment and occlusion of the distal segment of the stent. Based on the patient’s medical history and examination results, it was basically determined that the patient had severe in-stent restenosis, and he was admitted to the hospital for further treatment.
II. Treatment history
After admission, the patient was given an electrocardiogram, cardiac ultrasound, liver and kidney function, blood glucose, lipids, and three indicators of heart attack for a comprehensive assessment, including LDL 3.89 mmol/L, which exceeded the normal range and was much higher than the patient’s required control target of 1.4 mmol/L. Fortunately, myocardial damage markers and cardiac function tests were still normal. The patient was given aspirin tablets and Tegretol tablets for antiplatelet therapy, and Rosuvastatin calcium tablets and Elozumab injection for intensive lipid lowering and plaque stabilization, followed by metoprolol succinate extended-release tablets for anti-ischemia. Due to the patient’s combined diabetes and already developed coronary artery disease, the antihypertensive drug was adjusted to sakubatril valsartan sodium tablets, which have better target organ protection. A coronary angiogram was also arranged for the patient, which showed severe stenosis in the proximal segment of the right coronary, diffuse severe stenosis in the proximal to mid-stent, and occlusion in the distal segment of the stent. After opening the occlusion, it was found that there was also severe stenosis in the middle and distal segments of the right coronary, where there was no blood flow. Two stents were finally implanted in the distal segment of the right coronary, one stent was implanted in the proximal segment, and one drug balloon was used in the original stent.
Figure 1 Patient’s coronary angiography results
Before stent implantation and drug balloon treatment
After stent implantation and drug balloon treatment
III. Treatment effect
After hematologic reconstruction, the patient’s right coronary angiogram showed that the occlusion was successfully opened, the blood flow in the middle and distal right coronary segment was restored, and the in-stent stenosis was also properly treated. After about 6 days of hospitalization, the patient’s condition was controlled and stable, and no further chest pain symptoms occurred, so the patient was discharged home. At the follow-up visit 1 month after discharge, the patient reported no further episodes of chest pain and resumed normal life successfully. The patient also tried some moderate intensity exercises, such as brisk walking and bicycling, after discharge, which were tolerated. The patient was then given an adjustment of antihypertensive medication, and his blood pressure was maintained in the normal range. Under the intensive lipid regulating treatment, the blood test result at the 1-month follow-up showed that LDL-C dropped to 1.24 mmol/L, which reached the latest guideline requirement of 1.4 mmol/L or less, and the patient’s vascular lesion progression would be better controlled.
IV. Notes
We are glad that the patient’s disease is controlled after treatment, but the patient should adhere to a healthy lifestyle after discharge, refuse smoking and alcohol, regular rest and rest, moderate exercise, diet with low salt, low fat and low sugar, and also pay attention to monitoring blood pressure, blood glucose and blood lipids, which should be strictly controlled. In addition, patients should realize that chronic ischemic heart disease is a chronic disease, even if the blood vessels are opened through surgery, they should still insist on taking anti-platelet drugs and lipid-regulating drugs to control the progress of the disease and prevent thrombosis, and should not stop the drugs by themselves.
V. Personal insight
This patient has more cardiovascular risk factors, a history of hypertension for many years, and also a combination of diabetes, which are important diseases that promote atherosclerosis. The patient underwent stenting of the right coronary 1 year ago, but restenosis occurred, which is closely related to more underlying diseases, self-isolation of coronary treatment drugs and poorer ability of his own vascular repair.
Coronary atherosclerotic heart disease, commonly known as coronary heart disease, is the most important cause of chronic ischemic heart disease, and its treatment includes medication and surgery. Medication is the foundation, and for vessels with severe stenosis, blood perfusion to the heart needs to be restored through reconstructive surgery such as stenting or coronary artery bypass grafting, but antiplatelet drugs, as well as lipid-lowering drugs, still need to be taken regularly after surgery to control disease progression and to prevent the risk of thrombosis and restenosis that exists after stenting.