Chief complaints and history of present illness
A 69-year-old female patient presented with retrosternal pain that first occurred about 5 years ago during physical exertion (climbing stairs). The pain was accompanied by a feeling of air hunger, localized retrosternally and radiating to the corresponding area. At the time of the first episode, the patient was hospitalized, and a diagnosis of angina pectoris was established.
Over time, the nature of the pain changed: episodes at rest developed, including those unrelated to physical exertion, which is a sign of transition from stable angina to unstable angina. This is a key diagnostic point: the appearance of anginal pain at rest indicates the instability of the atherosclerotic plaque and requires urgent risk stratification for acute coronary syndrome.
When taking the history, it is important to clarify not only the presence of pain, but also provoking factors, duration, frequency, and whether the pain is relieved at rest or by nitroglycerin — this point was missed during the case review and noted as an omission in taking the patient's history.
Instrumental diagnostic data and treatment
5 years ago, the patient underwent an exercise ECG (treadmill test), which likely yielded a positive result, serving as an indication for coronary angiography. During the procedure, the identified stenosis was considered hemodynamically insignificant (a 30-40% range was discussed), and therefore no intervention was performed; medical therapy was prescribed.
In the winter of this year, due to increasing pain and signs of instability, the patient was re-hospitalized, repeat coronary angiography was performed, revealing an 80% stenosis of the left anterior descending artery extending to the main stem, as well as approximately 40% stenoses in the circumflex and right coronary arteries. Stenting of the left anterior descending artery was performed using a drug-eluting stent, whose antiproliferative coating prevents neointimal proliferation and restenosis within the first year after implantation.
Pharmacotherapy
Following stenting, the patient was prescribed dual antiplatelet therapy: clopidogrel 75 mg for 1 year and acetylsalicylic acid (trade name Trombo ACC) 100 mg indefinitely. Additionally, the patient takes:
- Beta-blocker (Concor) — reduces heart rate and, consequently, myocardial oxygen demand, thereby decreasing the risk of ischemia in the presence of the existing stenosis
- Antihypertensive therapy (Prestarium, formerly Prexanil) — blood pressure control also reduces myocardial workload and oxygen consumption
- Injections of Repatha (monoclonal antibodies regulating lipid metabolism) — prescribed due to statin intolerance, which in standard therapy prevents the progression of atherosclerosis
It was noted that prescribing acetylsalicylic acid before stenting would have been justified given the cardiovascular risk according to clinical guidelines, but in fact, the drug was only added after the procedure.
Past medical history and family history
The patient reports no concomitant chronic diseases (hypertension as an independent diagnosis, diabetes mellitus) at the time of the interview, although she takes antihypertensive medications and her blood pressure is controlled at 119-125/70-80 mm Hg. Past surgeries: removal of a benign kidney tumor (hormonal activity not specified) and uterine fibroid surgery in 2008.
Family history: mother suffered from arterial hypertension and heart disease, died at about 69 years of age; father died at 68 from lung cancer. The patient's son has arterial hypertension, and her daughter has a tendency toward hypotension. Taking a family history is important to assess hereditary predisposition to atherosclerosis and ischemic heart disease, as well as to rule out familial hypercholesterolemia, which is confirmed by early-onset dyslipidemia in the patient's children.
The total cholesterol level before surgery was 7.9 mmol/L, significantly exceeding the normal range (normal up to 5.0-5.2 mmol/L), confirming pronounced dyslipidemia. No bad habits (smoking, alcohol) were identified. Periodic lower extremity edema, worsening with prolonged sitting, was noted.
Pathophysiology and rationale for therapy
The clinical manifestations of ischemic heart disease are explained by insufficient myocardial oxygen supply due to coronary artery stenosis. With an increase in heart rate or blood pressure, myocardial oxygen demand rises, which, in the presence of limited coronary blood flow, provokes ischemia and symptoms of angina, and in severe cases, myocardial infarction. This explains the pathophysiological rationale for prescribing beta-blockers and antihypertensive drugs — reducing heart rate and blood pressure decreases myocardial oxygen demand.
Surgical treatment outlook
Given the multivessel disease (stented left anterior descending artery, stenoses of the circumflex and right coronary arteries of about 40% each), the progression of atherosclerosis is predicted, along with a likely future need for coronary artery bypass grafting, since repeat stenting in an already stented vessel is technically difficult and dangerous due to the risk of arterial dissection in the presence of calcification.
When planning three-vessel bypass surgery, the choice of conduits was discussed:
- Left internal thoracic artery — for the left anterior descending artery
- Radial artery — according to clinical guidelines, but in an older patient, it is preferable to avoid harvesting the radial artery due to the risk of hand dysfunction
- Greater saphenous vein — an alternative conduit, prior to harvesting which varicose veins must be ruled out via ultrasound, and the state of the lower extremity arteries (specifically the femoral artery) assessed, as atherosclerotic lesions in the leg arteries can impair surgical wound healing
The decision to perform surgery with or without cardiopulmonary bypass is made individually, taking into account the condition of the aorta (presence of ascending aortic atherosclerosis) and pulmonary function.
Key points
- The onset of anginal pain at rest indicates the transition from stable to unstable angina
- When taking a history, it is important to clarify drug dosages and whether pain is relieved by nitroglycerin
- Stenting requires dual antiplatelet therapy: clopidogrel for 1 year, aspirin indefinitely
- In case of statin intolerance, monoclonal antibodies regulating lipid metabolism are an alternative
- Family history is important for identifying hereditary predisposition and familial hypercholesterolemia
- Beta-blockers and antihypertensive therapy reduce myocardial oxygen demand by lowering heart rate and blood pressure
- Multivessel disease requires coronary artery bypass grafting with tailored conduits (internal thoracic artery, radial artery, greater saphenous vein)
- Prior to harvesting the greater saphenous vein, varicose veins must be ruled out and lower extremity arterial patency assessed