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Abstract: An 86-year-old male patient had intermittent precordial discomfort for 1 year, which worsened in the past month, especially after emotional stress or exertion, and was relieved by sublingual nitroglycerin during episodes of discomfort. The patient had a stent implanted 7 years ago for acute myocardial infarction and had a history of hypertension and diabetes mellitus, and was diagnosed with old myocardial infarction after examination. After optimizing the treatment and medication regimen, the patient’s precordial discomfort was relieved to disappear and all indexes improved.
Basic information】Male, 86 years old
Disease Type】Old myocardial infarction, hypertension, type 2 diabetes mellitus
Hospital】Harbin First Hospital
Date of consultation】June 2022
Treatment plan】Medication (injectable low molecular weight heparin sodium, isosorbide mononitrate injection, metoprolol tartrate tablets, sakubatril valsartan sodium tablets, ezetimibe tablets, isosorbide mononitrate tablets)
[Treatment period] 7 days of hospitalization
Treatment effect] The symptoms of discomfort were significantly relieved to disappear, and all indicators were improved
I. Initial consultation
The patient came to the hospital with the hospitalization order accompanied by his family. The patient had a stent 7 years ago because of acute myocardial infarction, and she was able to take oral antiplatelet, lipid-lowering and plaque stabilizing drugs on time. The symptoms were relieved by sublingual nitroglycerin. The patient took oral Benidipine hydrochloride tablets to lower blood pressure and subcutaneous insulin injections to lower sugar. Blood pressure and blood glucose were monitored occasionally, but he did not come to the hospital for a systematic physical examination after stenting. Other medications currently taken were metoprolol tartrate tablets, resulvastatin calcium tablets, and clopidogrel hydrogen sulfate tablets. The patient was then scheduled for an electrocardiogram, which showed sinus rhythm with ST-T changes. Blood pressure was measured: 159/86 mmHg, heart rate: 78 beats/min. Preliminary diagnosis: old myocardial infarction, hypertension, and type 2 diabetes mellitus.
II. Treatment history
After admission, the patient was firstly treated with anticoagulation therapy with injectable low molecular weight heparin sodium and intravenous pumping of vasodilator drug isosorbide mononitrate injection. The dosing regimen was adjusted according to the patient’s actual blood pressure and heart rate, and the oral dose of metoprolol tartrate tablets was increased to control the patient’s heart rate to 55-60 beats/min as much as possible. The patient’s previous oral Benidipine hydrochloride tablets were replaced with Sacubitril valsartan sodium tablets to help better prevent heart failure and left ventricular remodeling. The oral dose of Sacubitril valsartan sodium tablets was adjusted by monitoring heart rate and blood pressure during daily check-ups to control the patient’s blood pressure below 140/90 mmHg as much as possible. According to the patient’s biochemical examination, LDL was found to be uncontrolled and it was recommended to combine oral ezetimibe tablets to lower LDL to below 1.4 mmol/L as much as possible. The patient’s discomfort symptoms were significantly relieved in 3 days of systemic administration, and the isosorbide mononitrate injection was discontinued and replaced by oral isosorbide mononitrate tablets for alternative treatment.
III. Treatment effect
The coronary CT on the 3rd day of medication showed that the left anterior descending branch was changed after interventional stenting, no abnormality was seen in the lumen, and the lumen of the right coronary artery with mixed plaque was slightly stenosed, and it was confirmed that there was no serious stenosis of coronary vessels, so the oral medication was actively adjusted. Through systematic adjustment of medication, the patient’s symptoms of discomfort in the precordial region basically disappeared, and angina symptoms did not occur even after emotional excitement or moderate intensity exercise. No angina attacks were seen during the hospitalization. On the 7th day, a review was performed, and there was improvement in myocardial ischemia compared with the previous situation. Blood pressure: 130/75 mmHg, heart rate: 58 beats/min, and LDL was nearly normal, and all indicators were improved, so discharge was granted.
IV. Precautions
After the treatment, the patient’s symptoms were relieved and the indexes improved, so as a doctor, we are truly happy. It is important to pay attention to a low-salt and low-fat diet, to maintain regular rest and rest, to avoid straining and staying up late, to quit smoking and drinking, and to exercise properly to help improve cardiopulmonary function. When symptoms worsen or uncomfortable symptoms appear, it is important to communicate with a cardiologist in a timely manner to adjust the medication regimen and, if necessary, hospitalization. For patients with old myocardial infarction who have both hypertension and diabetes, it is more important to pay attention to strict control of blood pressure and blood sugar.
V. Personal insight
In actual clinical practice, some patients with old myocardial infarction think that their disease has been cured after stenting, so they do not need to come to the hospital for physical examination and review. Although coronary stenting treatment can help to improve the disease and prevent its progress, it does not mean that the disease has been cured, so patients need to come to the hospital for regular medical checkups, especially within 1 month, 3 months, 6 months and 1 year after stenting, and after 1 year, they can come to the hospital for medical checkups every 6 months to 1 year.