Case Summary: 54-Year-Old Caucasian Male Is Admitted

Case Summarya 54 Year Old Caucasian Male Is Admitted To the Emergency

Case Summary A 54-year-old Caucasian male is admitted to the emergency department with chest pain. The patient has a history of tobacco smoking and gastroesophageal reflux (GERD). There was no family history of cardiac events. An asymptomatic electrocardiogram (ECG) stress test was conducted. Cardiac catheterization and coronary computed tomography angiography (CCTA) would assist in diagnosing this patient.

Age: 54 years old Sex: Male Ethnicity: Caucasian Medical History History of tobacco smoking. No significant family history of cardiac events. BMI 29. Symptoms Three weeks of intermediate chest pain, radiating to his left arm and jaw. Examinations (Clinical Assays/Tests/Imaging) Physical Examination Blood pressure of 139/85 mmHg. Heart rate of 81 beats per minute. The intermediate pretest probability of CAD (coronary artery disease) is based on age and sex. Electrocardiogram (EKG) No ischemic changes, no left ventricular hypertrophy or left bundle branch block. Laboratory Investigations Serial troponin enzyme

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The patient’s presentation with recurrent chest pain, along with the abnormal findings on diagnostic tests, suggests a diagnosis of unstable coronary artery disease, specifically indicating significant coronary artery stenosis. The clinical picture including chest pain radiating to the left arm and jaw, combined with diagnostic evidence of severe stenosis in key coronary arteries, underscores the risk for myocardial infarction and warrants prompt and targeted intervention.

Initial assessment through examination, including serial troponin levels, and non-invasive tests such as ECG stress test, provide valuable information. The normal serial troponin levels indicate absence of ongoing myocardial necrosis; however, the symptoms and stress test results are concerning for ischemia. The stress test demonstrated maximum exertion capacity with normalization of T wave inversions, indicating that the ischemia, although significant, might be exertional. Importantly, the echocardiogram showing normal left ventricular function suggests that systolic function remains preserved, which is a favorable sign despite extensive coronary disease.

Further investigation with coronary computed tomography angiography (CCTA) provided detailed visualization of coronary anatomy and plaque morphology, revealing a significant 70% stenosis at the LAD’s origin, which is critical because the LAD supplies a large portion of the myocardium. The presence of non-calcified plaque extending over 4 mm signifies active atherosclerosis, which increases the risk of plaque rupture leading to acute coronary events. Additionally, moderate stenosis of other coronary branches underscores the diffuse nature of coronary artery disease (CAD) present in this patient.

The next step, cardiac catheterization, confirmed severe stenosis (>95%) in the LAD with partial perfusion (TIMI grade 2) indicating compromised blood flow. This invasive procedure is the gold standard for definitive diagnosis and allows for revascularization procedures such as percutaneous coronary intervention (PCI), which can restore adequate blood flow and prevent myocardial infarction. The findings of proximal severe stenosis in multiple arteries complicate the management, necessitating comprehensive risk stratification and treatment planning.

To summarize, the patient's clinical presentation and investigations strongly suggest advanced coronary artery disease, with a high risk for acute coronary syndrome. Immediate management should focus on stabilizing the patient, initiating anti-ischemics like antiplatelet agents, statins, beta-blockers, and considering revascularization depending on the patient’s stability and multidisciplinary team recommendations.

In terms of diagnosis, the differential includes stable angina, unstable angina, and non-ST-elevation myocardial infarction (NSTEMI). Given the lack of troponin elevation yet significant ischemia on tests, the likely diagnosis is unstable angina with high-grade stenosis in proximal LAD, warranting urgent intervention.

Additional investigations to assess the patient’s risk further could include stress echocardiography, myocardial perfusion imaging (MPI), and fractional flow reserve (FFR) measurement during catheterization. These modalities help quantify ischemia severity and guide revascularization decisions. For risk stratification, applying the Thrombolysis in Myocardial Infarction (TIMI) risk score is appropriate; the patient’s multiple high-risk features such as age over 50, heavy troponin-negative presentation, and high-grade stenoses suggest an intermediate to high risk category, influencing management toward invasive strategies.

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