A 72-year-old man presented to the emergency department with a 3-hour history of recurrent ischemic chest pain at rest. His presenting electrocardiogram showed 1 mm of ST-segment depression across leads V1-V4. He was hemodynamically stable on examination and was treated with low-molecular weight heparin, aspirin, beta blockers, clopidogrel (Plavix), and intravenous nitroglycerin (Minitran, Nitro-Bid, Nitro-Dur). The cardiac troponin I levels were elevated, at 4 μg/L, confirming a diagnosis of non—ST-segment elevation myocardial infarction. Coronary angiography was performed the next day, which showed an isolated proximal left anterior descending artery stenosis and was treated with a drug-eluting stent.
This patient's risk factors for coronary disease included modest obesity with a body mass index of 31 kg/m2; hypertension, which had been controlled with angiotensin-converting enzyme (ACE) inhibitors and a thiazide diuretic for 10 years; and a history of smoking. His low-density lipoprotein (LDL) cholesterol level on admission was 132 mg/dL and his high-density lipoprotein (HDL) cholesterol was 45 mg/dL. His recovery was normal, and he was discharged receiving an ACE inhibitor, a beta blocker, aspirin, clopidogrel, and high-dose atorvastatin therapy, as well a program of diet and exercise. One month after discharge, he was free from symptoms, and his systolic blood pressure was controlled at 128 mm Hg. His LDL cholesterol level had decreased to 64 mg/dL, and his HDL cholesterol level had increased marginally, to 47 mg/dL. Results of his treadmill test were negative. He had not lost any weight and was encouraged to comply with a program of reduced caloric intake and exercise as well as to continue taking his medication long term.