DRUGSUSED INISCHAEMICHEARTDISEASE 203FURTHER READING
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myocardial infarction. Cardiology Clinics2006; 24 : 37–51.Case history
A 46-year-old advertising executive complains of exercise-
related pain when playing his regular daily game of squash
for the past three months. Ten years ago he had a gastric
ulcer, which healed with ranitidine, and he had experi-
enced intermittent indigestion subsequently, but was other-
wise well. His father died of a myocardial infarct at the age
of 62 years. He smokes 20 cigarettes per day and admits
that he drinks half a bottle of wine a day plus ‘a few gins’.
Physical examination is notable only for obesity (body mass
index 30 kg/m^2 ) and blood pressure of 152/106 mmHg.
Resting ECG is normal and exercise ECG shows significant
ST depression at peak exercise, with excellent exercise tol-
erance. Serum total cholesterol is 6.4 mmol/L, triglycerides
are 3.8 mmol/L and HDL is 0.6 mmol/L. γ-Glutamyl transpep-
tidase is elevated, as is the mean corpuscular volume
(MCV). Cardiac catheterization shows a significant narrow-
ing of the left circumflex artery, but the other vessels are
free from disease.
Question
Decide whether each of the following statements is true or
false.
Immediate management could reasonably include:
(a)an ACE inhibitor;
(b)GTN spray to be taken before playing squash;
(c)no reduction in alcohol intake, as this would be
dangerous;
(d)referral for angioplasty;
(e)isosorbide mononitrate;
(f) a low dose of aspirin;
(g)nicotine patches;
(h)dexfenfluramine.
Answer
(a)False
(b)False
(c)False
(d)False
(e)True
(f) True
(g)False
(h)FalseComment
This patient has single-vessel disease and should be started
on medical management with advice regarding diet, smok-
ing and reduction of alcohol consumption. He should con-
tinue to exercise, but would be wise to switch to a less
extreme form of exertion. Taking a GTN spray before play-
ing squash could have unpredictable effects on his blood
pressure. A long-acting nitrate may improve his exercise
tolerance, and low-dose aspirin will reduce his risk of
myocardial infarction. In view of the history of ulcer and
indigestion, consideration should be given to checking for
Helicobacter pylori(with treatment if present) and/or reinsti-
tution of prophylactic acid suppressant treatment. His dys-
lipidaemia is a major concern, especially the low HDL
despite his high alcohol intake and regular exercise. It will
almost certainly necessitate some form of drug treatment
in addition to diet. His blood pressure should improve with
weight reduction and reduced alcohol intake. However, if
it does not and if the angina persists despite the above
measures, a β-adrenoceptor antagonist may be useful
despite its undesirable effect on serum lipids. If angina is
no longer a problem, but hypertension persists, a long-
actingα-blocker (which increases HDL) would be worth
considering.Because of the risks of haemorrhage, patients are not gener-
ally treated with fibrinolytic drugs if they have recently
(within the last three months) undergone surgery, are preg-
nant, have evidence of recent active gastro-intestinal bleeding,
symptoms of active peptic ulcer disease or evidence of severe
liver disease (especially if complicated by the presence of
varices), have recently suffered a stroke or head injury, have
severe uncontrolled hypertension, have a significant bleeding
diathesis, have suffered recent substantial trauma (including
vigorous chest compression during resuscitation) or require
invasive monitoring (e.g. for cardiogenic shock). The position
regarding diabetic or other proliferative retinopathy is contro-
versial. If ophthalmological advice is locally and immediately
available, this is no longer universally regarded as an absolute
contraindication to fibrinolysis.