Case Studies Angina The patient was a 48-year-old man admitted to the coronary care unit complaining of substernal chest pain. During the 4 months preceding admission, he noted chest pain radiating to his neck and jaw during exercise or emotional upsets. The pain dissipated when he discontinued the activity or relaxed. The results of his physical examination were essentially normal except for a systolic murmur heard best at the apex of the precordium and radiating into the left axilla. Studies Results Routine laboratory work Within normal limits (WNL) Cardiac enzyme studies Creatine phosphokinase (CPK), p. 167 235 units/L (normal: 55–170 units/L) CPK-MB, p. 171 12 ng/mL (normal: 0–3 ng/mL) Lactic dehydrogenase (LDH), p. 293 120 units/L (normal: 90–200 units/L) Serum aspartate aminotransferase (AST), p. 107 24 International units/L (normal: 5–40 International units/L) Troponins, p. 451 18 ng/mL Echocardiography, p. 820 Hypokinetic portion of the lateral left ventricle Electrocardiography (EKG), p. 485 Evidence of left ventricular hypertrophy Chest x-ray study, p. 956 WNL Exercise stress test, p. 481 Positive: pain reproduced; ST segment depression noted on EKG (normal: negative) Echocardiography, p. 820 Normal ventricular wall motion Transesophageal echocardiography (TEE), p. 840 Mitral regurgitation, dilated left atrium Lipoproteins, p. 304 HDL 29 mg/dL (normal: >45 mg/dL) LDL 189 mg/dL (normal: 60–180 mg/dL) VLDL 12 mg/dL (normal: 7–32 mg/dL) Homocysteine, p. 269 16 mol/L C-reactive protein (CRP), p. 165 22 mg/dL Cardiac catheterization, p. 950 All WNL except: Pressures Left ventricular systolic pressure 140 mm Hg (normal: 90–140 mm Hg) Aortic systolic pressure 130 mm Hg (normal: 90–140 mm Hg) Ventricular-aortic pressure gradient 5 mm Hg (normal: 0) Left ventricular function Cardiac output 3.5 L/min (normal: 3–6 L/min) End diastolic volume (EDV) 60 mL/m2 (normal: 50–90 mL/m2) End systolic volume (ESV) 22 mL/m2 (normal: 25 mL/m2) Stroke volume (SV) 38 mL/m2 (SV = EDV − ESV) Ejection fraction 0.63 (normal: 0.67 ± 0.07) Cineventriculography Mitral regurgitation present, normal muscle function (normal: normal ventricle) Analysis of O2 gas content, p. 98 No shunting (normal: no shunting) Coronary angiography (coronary cineangiography), p. 950 90% narrowing of left coronary artery (normal: no narrowing) Cardiac radio-nuclear scanning, p. 733 Scans normal showed localized area of decreased perfusion and poor muscle function in the myocardium during exercise Cholesterol, p. 138 502 mg/dL (normal: <200 mg/dL) Triglycerides, p. 447 198 mg/dL (normal: 40–150 mg/dL) Diagnostic Analysis Cardiac radio-nuclear scanning, EKG, and studies ruled out the possibility of MI. Troponins and serial cardiac enzyme indicated cardiac ischemia. Stress testing and a nucleotide scan indicated that the patient was having exercise-related myocardial ischemia (angina). Echocardiography indicated that the heart muscle at the site of ischemia was functioning poorly. Transesophageal echocardiography indicated that the patient had mitral regurgitation. Cardiac catheterization with cineventriculography demonstrated near-normal ventricular function, and coronary angiography indicated significant narrowing of the left coronary artery. Mitral regurgitation was also seen. The patient’s angina was then thought to be caused by the coronary artery disease. Open heart surgery was performed. The patient's mitral valve was replaced with a prosthesis, and an aortocoronary artery bypass graft was performed. Postoperatively, he had a large pericardial effusion. This diminished his heart function. He underwent pericardiocentesis, and his function improved. Because his serum lipids study showed type IIa hyperlipidemia, a low-cholesterol diet and cholesterol-lowering agents were prescribed. The other cardiac risk factors did indicate increased risk for coronary heart disease. Six months later he was asymptomatic and jogging 3 miles per day. Questions: 1. Based on the ratio of cholesterol to HDL, what is the patient’s risk for coronary heart disease? 2. If these blood tests were drawn 1 year ago, what treatment would have been indicated? 3. Could surgery have been avoided?
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