Title: Managing Recurrent Chest Pain in Elderly Patients: A Case of Unstable Angina
Unstable angina is a serious cardiovascular condition that often presents with unpredictable chest pain and requires immediate medical attention. This article explores the case of a 67-year-old female patient who experienced repeated episodes of chest discomfort and pain due to unstable angina. Despite the recommendation for interventional treatment, the patient opted for a conservative approach involving intensive medication therapy and lifestyle changes, which led to significant symptom relief and improved overall health outcomes.
Case Overview
Patient: Female, 67 years oldDiagnosis: Unstable anginaTreatment Location: The First Hospital of Harbin CityDate of Treatment: May 2022Treatment Approach: Pharmacological therapy with a combination of anticoagulant, antiplatelet, antihypertensive, and lipid-lowering agentsHospitalization Duration: 7 days, followed by 3–6 months of outpatient follow-upOutcome: Significant symptom improvement, better blood pressure and lipid control, reduced frequency of angina episodes
Initial Presentation and Diagnosis
The patient arrived at the hospital accompanied by family members with a hospitalization order. Upon initial consultation, it was revealed that she had not undergone comprehensive cardiovascular screening previously. She had been experiencing intermittent chest tightness and pain for one week, with symptoms worsening over the past two days. Episodes often occurred during physical exertion or emotional stress, and even at night while sleeping, lasting from 3 to 20 minutes. Sublingual nitroglycerin failed to provide relief. She had a history of hypertension for 10 years, managed with amlodipine, maintaining a blood pressure of approximately 150/90 mmHg and a resting heart rate of 90 bpm. Although she did not smoke or drink, she was exposed to secondhand smoke and followed a generally low-salt, low-fat diet.
An electrocardiogram (ECG) revealed sinus rhythm with ST-T wave changes. Coronary CT angiography showed significant stenosis in the left anterior descending artery, moderate narrowing in the circumflex artery, and mild stenosis in the right coronary artery. Based on these findings and the clinical presentation, a diagnosis of unstable angina was made.
Treatment Plan and Progress
Pharmacological Intervention
Given the diagnosis, immediate treatment was initiated with low-molecular-weight heparin and intravenous isosorbide dinitrate. Cardiac enzyme tests were negative, and ECG monitoring did not reveal any dynamic changes, ruling out acute myocardial infarction. The patient was prescribed aspirin, rosuvastatin, and metoprolol tartrate. Blood pressure management was optimized by switching to perindopril, and the metoprolol dosage was adjusted to achieve a target resting heart rate of around 60 bpm.
Antiplatelet and Lipid-Lowering Therapy
Due to the patient's refusal of coronary angiography and subsequent percutaneous coronary intervention (PCI), a coronary CT scan was performed instead. In light of the severe stenosis detected, dual antiplatelet therapy was initiated with clopidogrel in addition to aspirin. With a low-density lipoprotein (LDL) level of 4.7 mmol/L, ezetimibe was added to intensify lipid-lowering therapy.
Transition to Oral Therapy
As symptoms improved, intravenous isosorbide dinitrate was replaced with oral isosorbide mononitrate. Despite recommendations for PCI, the patient and her family opted to continue with medical management alone.
Outcome and Follow-Up
After seven days of hospitalization and optimized pharmacological therapy, the patient's symptoms significantly improved. While chest discomfort could still be triggered by heavy physical activity or emotional stress, these episodes became much less frequent. Blood pressure was maintained below 130/80 mmHg, and heart rate was controlled around 60 bpm. LDL cholesterol levels dropped below 1.4 mmol/L with aggressive lipid management. Repeat ECG showed improvement in myocardial ischemia changes, and the patient was discharged with instructions for regular medication adherence and follow-up visits every 3–6 months.
Key Recommendations for Patients with Unstable Angina
For patients diagnosed with unstable angina, consistent medication use is crucial. Drugs such as aspirin, clopidogrel, and rosuvastatin play a vital role in preventing disease progression and reducing cardiovascular risk. Monitoring and controlling blood pressure and heart rate are essential to prevent angina episodes and further cardiac complications.
While the patient declined interventional treatment, it is strongly recommended that individuals with significant coronary artery stenosis consider PCI to reduce the risk of sudden cardiac death. Lifestyle modifications, including a heart-healthy diet rich in fruits and vegetables, avoiding overeating, and managing stress and fatigue, are also vital. Regular medical check-ups every 3–6 months are advised, with particular attention to maintaining LDL levels below 1.4 mmol/L.
Clinical Insights and Preventive Strategies
Unstable angina represents a critical stage between stable angina and myocardial infarction, signaling a high-risk cardiac condition. Early coronary angiography is essential to assess the severity of arterial narrowing and determine the need for intervention. In this case, despite the presence of multiple risk factors—including uncontrolled hypertension, secondhand smoke exposure, and hyperlipidemia—timely medical therapy significantly improved the patient's condition.
For elderly patients with chronic conditions, regular health screenings and proactive disease management are key to preventing severe coronary events. Comprehensive lifestyle changes and adherence to prescribed medications can significantly improve prognosis and quality of life.