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The management of a young, active, asymptomatic patient with evidence of a prior myocardial infarction raises several options for treatment.
A 39-year-old male smoker with no other prior medical history presented to clinic for medical clearance for his job as a corrections officer after having an abnormal electrocardiogram (ECG). Five months ago, he had an episode of left anterior chest pain that occurred while sitting on the couch. The pain was sharp, associated with nausea, and radiated to the left arm; it waxed and waned for 5 hours. He did not seek medical attention at the time. The pain spontaneously resolved and has not recurred. He had no symptoms; no angina, dyspnea, orthopnea, palpitations, or syncope. He remained active, working on his farm with heavy lifting and has not had to limit his activity in any way. Physical examination was benign with cardiac examination showing normal rate, regular rhythm, with no murmurs, rubs, or gallops.
ECG showed normal sinus rhythm with old anteroseptal infarct. TTE showed akinesis of the anteroseptum and apex, LVEF 45-49%, and no significant valvular pathology. This history is concerning for someone his age and prompted us to consider several different management options, including left heart catheterization to evaluate the coronaries, noninvasive ischemia testing to stratify risk, and viability testing to determine if revascularization would be warranted. The patient refused all of these options, but agreed to treadmill testing since he was asymptomatic and his job as a corrections officer was his top priority. The patient exercised for 11:19 on Bruce Protocol, achieving 13.4 METS, maximum heart rate of 155 bpm (85% of maximum predicted). At baseline, ECG showed an anteroseptal infarct with mild residual ST elevation and T wave inversion; no additional ST-T wave changes with observed exercise. The patient was treated with aspirin, statin, beta blocker, and ace inhibitor with smoking cessation also strongly encouraged.
This case demonstrates the challenges in the management of a young, active, asymptomatic patient with prior anterior myocardial infarction who now requires medical clearance for employment.
Sunday, March 30, 2014, 3:45 p.m.-4:30 p.m.
Session Title: FIT Clinical Decision Making: Interventional Cardiology and Acute Coronary Syndrome
Abstract Category: Stable Ischemic Heart Disease
Presentation Number: 1209-08
- 2014 American College of Cardiology Foundation