How I Treat: A Woman With Multiple Cardiovascular Risk Factors, Chest Pain, Shortness of Breath
Seth Martin, MD, MHS | Johns Hopkins University School of Medicine (Baltimore, MD)
A 48-year-old woman presents to the emergency department with acute chest pain and shortness of breath.
History. The patient’s medical history includes acute myocardial infarction status post-single-vessel percutaneous coronary intervention 5 years previously. Her initial evaluation in the emergency department, including serial electrocardiograms and troponin measurements, is consistent with non-ST elevation myocardial infarction. She also has a history of hyperlipidemia. A review of older lipid panels shows an untreated lipid panel with TC 372 mg/dL, TG 90 mg/dL, HDL-C 47 mg/dL, and LDL-C 304 mg/dL. Her current treated LDL-C level is 127 mg/dL on atorvastatin 80 mg daily and ezetimibe 10 mg daily. Further, the patient’s history includes diabetes mellitus, hypertension, and rheumatoid arthritis.
The patient’s father, brother, and paternal uncle had hyperlipidemia and a myocardial infarction at 57, 50, and between 40 and 50 years of age, respectively. The patient’s brother and paternal uncle died of their initial myocardial infarctions.
Physical examination. The patient’s heart rate is 58 beats per minute, her blood pressure is 122/64 mmHg, her temperature is 36.83 degrees Celsius, her respiratory rate is 18 breaths per minute, and her oxygen saturation is 98% on room air.
The patient’s examination is notable for bilateral corneal arcus and thickened Achilles tendons. The patient’s chest shows a sternotomy scar that is clean, dry, and intact. The lungs are clear to auscultation, with no wheezes, rhonchi, or crackles. On cardiac examination, the precordium is quiet. The point of maximal impulse is normal, as are S1 and S2, with no murmurs, rubs, or gallops and a regular rate and rhythm. The abdomen is soft and non-tender without bruits. There is no cyanosis, clubbing, or edema. The patient has intact posterior tibial pulses.
Treatment and management. The patient is admitted to cardiology and treated with guideline-directed medical therapy for acute coronary syndrome. She is referred to the cardiac catheterization laboratory, where she is found to have progression of her coronary artery disease, now with multivessel disease.
She undergoes revascularization via coronary artery bypass grafting, initially recovers in the intensive care unit, and is transferred to a care team on the cardiology floor. The patient is recovering well from bypass surgery and arrangements are being made for discharge. In addition to referring her for routine medical and cardiology follow-up, she is referred for advanced lipid management because of a concern for familial hypercholesterolemia and the need for further intensification of lipid therapy (e.g., the addition of a PCSK9 inhibitor). In addition to counseling the patient on the importance of adherence to her guideline-directed therapies for secondary prevention of atherosclerotic cardiovascular disease and follow-up with the scheduled appointments, the patient is counseled about the benefits of participating in cardiac rehabilitation and given a referral at discharge.
Cardiac rehabilitation carries a class 1A guideline recommendation from the American Heart Association given the strong evidence for its benefits, which includes improved quality of life and a reduction in morbidity and mortality after cardiac surgery, cardiac procedures, and cardiovascular events.1 Its core components include supervised exercise, dietary counseling, and risk factor management. Patients typically participate three times per week for 12 weeks (total of 36 sessions) in person at a cardiac rehabilitation center, while home-based options for participation in cardiac rehab are becoming increasingly available thanks to digital technologies and telemedicine.2
