66-Year-Old Man Finds Relief from Coronary Atherosclerosis Through Targeted Medication
When Mr. Li, a 66-year-old patient, first came to the hospital complaining of persistent chest pain and occasional numbness in his fingertips and tongue, it marked the beginning of a journey that would lead to a clearer understanding of his condition and a successful treatment plan. With a prior diagnosis of hypertension and a history of insomnia and anxiety, Mr. Li's case required a thorough and nuanced approach to ensure an accurate diagnosis and effective care.
Understanding the Diagnosis
Upon admission, Mr. Li's blood pressure was measured at 130/70 mmHg, and his heart rate was a steady 57 beats per minute. An ultrasound revealed plaque formation in both carotid arteries and reduced left ventricular diastolic function. These findings, combined with his symptoms and medical history, led to a diagnosis of coronary atherosclerosis, hypertension, carotid artery sclerosis, and cardiac neurosis.
Treatment Plan and Medical Intervention
Given that Mr. Li had already been managing his blood pressure effectively with Irbesartan, the focus shifted to investigating the cause of his chest pain. A coronary CT scan was performed, revealing mild luminal narrowing due to mixed plaques in the left anterior descending artery. Since the narrowing was less than 50%, a diagnosis of coronary atherosclerosis—rather than full-blown coronary artery disease—was confirmed.
Blood tests also revealed elevated triglyceride levels at 4.7 mmol/L. To address this, Mr. Li was prescribed Bezafibrate to lower triglycerides. His treatment regimen also included Aspirin Enteric-Coated Tablets to prevent clot formation, Trimetazidine Hydrochloride Tablets to improve myocardial metabolism, and intravenous Shuxuening Injection to enhance circulation. Additionally, Estazolam Tablets were added to help manage his insomnia and anxiety.
Positive Outcomes After Treatment
After seven days of inpatient treatment, Mr. Li experienced a significant reduction in chest pain. Follow-up ECGs showed improvement in myocardial ischemia, and the numbness in his tongue and fingertips had subsided. His triglyceride levels dropped below 1.7 mmol/L, and his sleep improved considerably with the help of Estazolam. One month after discharge, during a follow-up visit, Mr. Li remained stable with no recurrence of symptoms.
Lifestyle Recommendations for Long-Term Health
While medication played a key role in Mr. Li's recovery, lifestyle modifications were equally important. He was advised to adopt a low-salt, low-fat diet rich in fruits, vegetables, and whole grains. Regular physical activity was encouraged—specifically, at least 30 minutes of exercise on five days of the week—to help manage weight and support cardiovascular health.
In addition to these changes, Mr. Li was urged to maintain a consistent sleep schedule, reduce stress through relaxation techniques, and continue taking prescribed medications. Annual health checkups were recommended to monitor his blood pressure and detect any potential complications early.
Insights for Similar Cases
Mr. Li's case highlights the importance of a comprehensive approach when evaluating chest pain in elderly patients with underlying conditions. While coronary artery disease is a common concern, it's crucial to consider other contributing factors such as atherosclerosis without significant stenosis, anxiety, or sleep disturbances.
Clinicians should remain vigilant in distinguishing between various causes of chest discomfort. In cases like Mr. Li's, where symptoms are not directly linked to severe arterial blockage, a combination of targeted pharmacotherapy and lifestyle adjustments can lead to meaningful symptom relief and improved quality of life.