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12.9: Case 2

  • Page ID
    42804
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    Case 2: 52-year old woman with microvascular disease

    Patient is referred for a second opinion to the cardiologist with complaints of tiredness and chest pain. She was evaluated 3 months earlier with chest pain. Cardiovascular analysis then showed no cardiac pathology.

    History

    Patient, who runs every week 10 kilometers, complains that she noticed shortness of breath and tiredness during her weekly run which she describes as abnormal. During running she has no chest pain. She does however experience chest pain, which she describes as “heavy" feeling on the chest, when there is an abrupt change of temperature. Also slight radiation to the left arm.

    Risk factors

    Menopausal, positive family history, smoking history (she quit 15 years ago), obstetric history normal, Alcohol consumption: 2U/day

    Physical examination

    BMI=26, blood pressure: 145/90 mmHg, pulse: 70 r.a., normal heart sounds, no murmurs.

    Lab: glucose

    5 mmol/L, Total cholesterol: 6,9 mmol/L, LDL-cholesterol: 3,5 mmol/L, HDL cholesterol: 1,3 mmol/L, Triglycerides: 4,5 mmol/L.

    Additional Cardiac Investigation

    ECG and exercise stress test were completely normal. Vascular scanning of the carotid arteries showed moderate plaque formation in de the carotid bulb. No chest pain during exercise. Myocardial perfusion scan showed ischemia in the inferior segments of the heart. Cardiac catheterization: vessel wall irregularities in all coronary arteries, no significant obstructions.

    Follow-up

    Blood pressure and lipid profiles was optimized with ACE inhibition and a statin. She was advised to lose weight and drink less alcohol with regard to her elevated triglycerides. She received a low dose b-blocker and was without complaints within 3 months.

    Learning points

    • Complaints without obstructive heart disease
    • Risk factors should always be optimized, blood pressure in lipid profile was inadequate
    • Limitation of diagnostic tests.

    This page titled 12.9: Case 2 is shared under a CC BY-NC-SA 3.0 license and was authored, remixed, and/or curated by de Jong and van der Waals Eds. (Cardionetworks Foundation and the Health[e]Foundation) via source content that was edited to the style and standards of the LibreTexts platform.

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