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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Identify modifiable risk factors for ischemic heart disease (IHD), and discuss the potential benefit to be gained by their modification in an individual patient.

  • Optimize medical therapy in a patient with persistent angina considering response to current therapy and the presence of comorbidities.

  • Assess clinical response to antianginal therapy by identifying relevant monitoring parameters for efficacy and adverse effects.

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PATIENT PRESENTATION

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Chief Complaint

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“Doc, these drugs just aren’t working for my chest pain anymore.”

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HPI

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Jack Palmer is a 72-year-old man with coronary artery disease. He is an avid golfer and prefers to walk the course, but this is becoming progressively more difficult for him due to frequent angina. He has had two coronary artery bypass operations in the past. A coronary angiogram performed 1 month ago revealed significant disease in the RCA proximal to his graft, but this was considered high risk for angioplasty. His dose of isosorbide mononitrate was increased at that time from 60 to 120 mg once daily. This had no effect on his angina. He is still using about 30 nitroglycerin tablets a week, and these do relieve his chest pain. He reports that most often the chest discomfort comes on with activity, such as walking up slight inclines on the golf course. The discomfort is located in the center of his chest and rated 3–4/10 on average. He reports that the chest discomfort slowly fades as he slows his activity. He also complains of occasional lightheadedness with a pulse around 50 bpm and SBP near 100 mm Hg.

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PMH

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  1. Acute anterior wall MI with CABG surgery in 2009

  2. Posterior lateral MI in 1990 and PTCA to the circumflex at that time

  3. Dyslipidemia

  4. Chronic low back pain

  5. Depression

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FH

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Noncontributory for premature CAD.

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SH

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Retired dairy farmer, lives with wife, drinks occasionally, previous smoker—quit in 1998

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Meds

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  • Carvedilol 6.25 mg PO twice daily

  • Lisinopril 5 mg PO once daily

  • Aspirin 325 mg PO once daily

  • Isosorbide mononitrate, extended release 120 mg PO once daily

  • Diltiazem, extended release 240 mg PO once daily

  • St. John’s wort 300 mg PO three times daily

  • Celecoxib 200 mg PO once daily

  • Simvastatin 40 mg PO once daily

  • Nitroglycerin 0.4 mg SL PRN

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All

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NKDA

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ROS

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No fever, chills, or night sweats. No recent viral illnesses. No shortness of breath; occasional cough with cold weather. No nausea, vomiting, diarrhea, constipation, melena, or hematochezia. No dysuria or hematuria. No myalgias or arthralgias.

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Physical Examination

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Gen
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Pleasant, cooperative man ...

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