100 Cases in Clinical Medicine

CASE 97: ROUTINE FOLLOW-UP

History

Four months ago a 47-year-old publican was admitted to hospital with acute chest pain.
A subendocardial inferior myocardial infarction was diagnosed and he was treated with
thrombolytics and aspirin. After discharge he complained of angina, and coronary
angiography was performed. This showed severe triple-vessel disease not suitable for
stenting, and coronary artery bypass grafting was performed. He is attending a cardiac
rehabilitation clinic and he has had no further angina since his surgery. He has a strong
family history of ischaemic heart disease, with his father and two paternal uncles having
died of myocardial infarctions in their 50 s; his 50-year-old brother has angina. He is mar-
ried with two children. He smokes 25 cigarettes per day and drinks at least 40 units of
alcohol per week. He is taking atenolol and aspirin.

Examination

He is slightly overweight (85 kg; body mass index)28). He has tar-stained nails. He has
bilateral corneal arcus, xanthelasmata around his eyes and xanthomata on his Achilles
tendons. He has a well-healed midline sternotomy scar. His pulse is 64/min regular, blood
pressure 150/84 mmHg. He has no palpable pedal pulses. His respiratory, gastrointestinal
and neurological systems are normal.

Normal

Haemoglobin 16.2 g/dL 13.3–17.7 g/dL

White cell count 10.0% 109 /L 3.9–10.6% 109 /L

Platelets 336 % 109 /L 150–440% 109 /L

Sodium 135 mmol/L 135–145 mmol/L

Potassium 3.9 mmol/L 3.5–5.0 mmol/L

Urea 3.4 mmol/L 2.5–6.7 mmol/L

Creatinine 82 &mol/L 70–120&mol/L

Bilirubin 16 mmol/L 3–17 mmol/L

Alanine transaminase 33 IU/L 5–35 IU/L

Alkaline phosphatase 72 IU/L 30–300 IU/L

Gamma-glutamyl transpeptidase 68 IU/L 11–51 IU/L

Cholesterol 12.2 mmol/L !5.5 mmol/L

Triglyceride 2.30 mmol/L 0.55–1.90 mmol/L

Very low-desnity lipoprotein (VLDL) 0.34 mmol/L 0.13–0.65 mmol/L

Low-density lipoprotein (LDL) 8.5 mmol/L 1.6–4.4 mmol/L

High-density lipoprotein (HDL) 0.6 mmol/L 0.9–1.9 mmol/L

Urinalysis: no abnormality detected

INVESTIGATIONS

Questions

• What is the metabolic abnormality present?


• What advice would you give this man?