Case Studies AnginaThe patient was a 48-year-old man admitted to the coronary care unit complaining of substernal chest pain. During the 4 months preceding admission, he noted chest pain radiating to his neck and jaw during exercise or emotional upsets. The pain dissipated when he discontinued the activity or relaxed. The results of his physical examination were essentially normal except for a systolic murmur heard best at the apex of the precordium and radiating into the left axilla.StudiesResultsRoutine laboratory workWithin normal limits (WNL)Cardiac enzyme studiesCreatine phosphokinase (CPK), p. 167235 units/L (normal: 55–170 units/L)CPK-MB, p. 17112 ng/mL (normal: 0–3 ng/mL)Lactic dehydrogenase (LDH), p. 293120 units/L (normal: 90–200 units/L)Serum aspartate aminotransferase (AST), p. 10724 International units/L (normal: 5–40 International units/L)Troponins, p. 45118 ng/mLEchocardiography, p. 820Hypokinetic portion of the lateral left ventricleElectrocardiography (EKG), p. 485Evidence of left ventricular hypertrophyChest x-ray study, p. 956WNLExercise stress test, p. 481Positive: pain reproduced; ST segment depression noted on EKG (normal: negative)Echocardiography, p. 820Normal ventricular wall motionTransesophageal echocardiography (TEE), p. 840Mitral regurgitation, dilated left atriumLipoproteins, p. 304HDL29 mg/dL (normal: >45 mg/dL)LDL189 mg/dL (normal: 60–180 mg/dL)VLDL12 mg/dL (normal: 7–32 mg/dL)Homocysteine, p. 26916 mol/LC-reactive protein (CRP), p. 16522 mg/dLCardiac catheterization, p. 950All WNL except:PressuresLeft ventricular systolic pressure140 mm Hg (normal: 90–140 mm Hg)Aortic systolic pressure130 mm Hg (normal: 90–140 mm Hg)Ventricular-aortic pressure gradient5 mm Hg (normal: 0)Left ventricular functionCardiac output3.5 L/min (normal: 3–6 L/min)End diastolic volume (EDV)60 mL/m2 (normal: 50–90 mL/m2)End systolic volume (ESV)22 mL/m2 (normal: 25 mL/m2)Stroke volume (SV)38 mL/m2 (SV = EDV − ESV)Ejection fraction0.63 (normal: 0.67 ± 0.07)CineventriculographyMitral regurgitation present, normal muscle function (normal: normal ventricle)Analysis of O2 gas content, p. 98No shunting (normal: no shunting)Coronary angiography (coronary cineangiography), p. 95090% narrowing of left coronary artery (normal: no narrowing)Cardiac radio-nuclear scanning, p. 733Scans normal showed localized area of decreased perfusion and poor muscle function in the myocardium during exerciseCholesterol, p. 138502 mg/dL (normal: <200 mg/dL)Triglycerides, p. 447198 mg/dL (normal: 40–150 mg/dL)Diagnostic AnalysisCardiac radio-nuclear scanning, EKG, and studies ruled out the possibility of MI. Troponins and serial cardiac enzyme indicated cardiac ischemia. Stress testing and a nucleotide scan indicated that the patient was having exercise-related myocardial ischemia (angina). Echocardiography indicated that the heart muscle at the site of ischemia was functioning poorly. Transesophageal echocardiography indicated that the patient had mitral regurgitation. Cardiac catheterization with cineventriculography demonstrated near-normal ventricular function, and coronary angiography indicated significant narrowing of the left coronary artery. Mitral regurgitation was also seen. The patient’s angina was then thought to be caused by the coronary artery disease. Open heart surgery was performed. The patient's mitral valve was replaced with a prosthesis, and an aortocoronary artery bypass graft was performed. Postoperatively, he had a large pericardial effusion. This diminished his heart function. He underwent pericardiocentesis, and his function improved. Because his serum lipids study showed type IIa hyperlipidemia, a low-cholesterol diet and cholesterol-lowering agents were prescribed. The other cardiac risk factors did indicate increased risk for coronary heart disease. Six months later he was asymptomatic and jogging 3 miles per day.Questions:1.         Based on the ratio of cholesterol to HDL, what is the patient’s risk for coronary heart disease?2.         If these blood tests were drawn 1 year ago, what treatment would have been indicated?3.         Could surgery have been avoided?

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