Detailed Treatment Process
This patient owned a property in the urban-rural fringe area. His wife had passed away several years earlier, so he sometimes lived there alone. On one occasion, he experienced angina symptoms for the first time. He did not know what angina was and only felt a heavy, oppressive pain in his chest that lasted for several days. When he could no longer bear it, he went to a nearby community hospital. The community hospital performed an electrocardiogram and prescribed some medications, including enteric-coated aspirin. These drugs are slow-acting, whereas the standard emergency treatment for an acute myocardial ischemia episode is sublingual nitroglycerin. However, the community hospital doctor did not prescribe nitroglycerin. After taking the medication, the chest pain did not improve. Why didn’t he return to the city for treatment? Because there was only one bus route connecting the area to the city, and the road was often blocked by large container trucks — a single intersection could be jammed for more than half an hour. The bus ride back to the city took several hours, and there was no guarantee of a seat. The patient was already in his seventies and was in the middle of an angina attack. He simply did not have the strength to make the journey back to the city alone. He also did not want to trouble his children for help. So he had no choice but to endure it where he was. A few days later, he returned to the community hospital. Once again, he was given only slow-acting drugs such as aspirin. The pain remained, and he could only continue to endure it. One day while out buying groceries, a neighbor noticed his ashen complexion and asked what was wrong. This neighbor had a personal history of angina — more importantly, his son was a doctor at that very community hospital. The neighbor immediately took him to see his son and said: “Give him the same medicine you gave me.” The son wrote “nitroglycerin” directly in the medical record book without hesitation. This time, there were no lengthy notes or unnecessary words — just the prescription: nitroglycerin. After taking nitroglycerin, the chest tightness and pain disappeared rapidly. With his strength returning, he boarded a bus back to his home in the city. His city residence was right next to a large hospital, so he was admitted without delay. The following is the discharge summary: Ward: CCU Sex: Male Age: 77 Date of Admission: August 10 Date of Discharge: September 7 Length of Stay: 28 days Outpatient Diagnosis: Coronary atherosclerotic heart disease; unstable angina; arrhythmia; bradycardia; chronic total cardiac insufficiency NYHA Class III; primary hypertension Grade 3, very high risk; type 2 diabetes mellitus; benign prostatic hyperplasia Admission Diagnosis: Coronary atherosclerotic heart disease; unstable angina; arrhythmia; bradycardia; chronic total cardiac insufficiency NYHA Class III; primary hypertension Grade 3, very high risk; type 2 diabetes mellitus; benign prostatic hyperplasia Discharge Diagnosis: Coronary atherosclerotic heart disease; unstable angina; arrhythmia: sinus bradycardia; chronic total cardiac insufficiency NYHA Class III; primary hypertension Grade 3, very high risk; type 2 diabetes mellitus; acute bronchitis; benign prostatic hyperplasia; cholecystitis (mild) Chief Complaints and Signs on Admission: Male patient, 77 years old, admitted due to “episodic chest tightness and chest pain for two weeks.” Physical examination: Alert, breathing unlabored, BP 126/68 mmHg, HR 58 bpm, regular rhythm, cardiac monitor indicating sinus rhythm, coarse breath sounds in both lungs, scattered fine moist crackles audible in the right lower lobe, abdomen soft with no tenderness, no edema in both lower extremities, normal muscle strength in all four limbs, no pathological reflexes elicited. Key Laboratory Results: Potassium 4.5 mmol/L; Sodium 136 mmol/L; Hemoglobin 112 g/L; Red blood cells 4.01 × 10¹²/L; White blood cells 5.2 × 10⁹/L; Granulocyte percentage 56.2%; Uric acid 502 μmol/L; Urea 6.6 mmol/L; Creatinine 105 μmol/L; BNP 88 pg/mL; Glycated hemoglobin 8.5%; D-dimer 94 μg/L; Fibrinogen 3.2 g/L; Total bilirubin 14 μmol/L; Albumin 34 g/L; Gamma-glutamyl transferase 56 U/L; Total cholesterol 4.40 mmol/L; Triglycerides 0.68 mmol/L; HDL 1.02 mmol/L; LDL 3.33 mmol/L; Alanine aminotransferase 18 U/L; Platelet aggregation 79.5%; AFP 0.9 ng/mL; CEA 0.9 ng/mL; PSA 3.5 ng/mL; TSH 3.05 μIU/mL; T4 7.74 μg/dL; FT3 1.62 pg/mL; FT4 1.30 ng/dL; T3 0.76 ng/mL; FPSA 0.6 ng/mL; CYFRA21-1 2.4 ng/mL; CA19-9 11.8 U/mL; CA72-4 0.3 U/mL; NSE 12.2 ng/mL; Ketones negative; Cardiac enzyme panel negative; Coagulation times normal; Stool routine and fecal occult blood negative. Special Investigations and Key Consultations (with dates and record numbers): ECG: Sinus bradycardia, left ventricular hypertrophy with ST-T changes, increased left atrial load, abnormal Q waves in inferior leads. August 19 chest CT: Increased bronchovascular markings in both lungs, calcified nodule in right upper lobe, bilateral pleural effusion. September 1 chest X-ray: Increased bronchovascular markings in both lungs, cardiothoracic ratio 0.52. 24-hour Holter monitoring: Sinus rhythm (42–75 bpm), 5 premature atrial contractions, no premature ventricular contractions, maximum ischemic ST-segment depression recorded at 0.20 mV. Ultrasound: Mildly coarsened hepatic parenchymal echogenicity, mild cholecystitis. Echocardiogram: Enlargement of left atrium and left ventricle, degenerative aortic valve changes with mild regurgitation, mild mitral regurgitation, left ventricular function within normal limits. Sputum culture: Neisseria species and Streptococcus viridans. Coronary angiography (August 20): Left main coronary artery 50% stenosis; mid left anterior descending artery 95% stenosis; mid left circumflex artery 90% stenosis; proximal right coronary artery 40–50% stenosis, mid right coronary artery 98% stenosis. Coronary artery bypass grafting recommended. Renal artery angiography: right renal artery ostial stenosis 60–70%, left renal artery negative. Clinical Course and Treatment Outcomes (including procedures, dates, blood transfusions, and resuscitation): Following admission, relevant investigations were completed. Treatment included: anticoagulation and antiplatelet therapy (clopidogrel); antihypertensive and cardiac remodeling therapy (valsartan); hypoglycemic therapy (glimepiride); coronary vasodilators (isosorbide dinitrate, isosorbide mononitrate); diuresis (furosemide) and aldosterone antagonism (spironolactone); plaque stabilization (simvastatin); myocardial nutrition and cardiac support (fructose-1,6-diphosphate sodium, dopamine); laxative therapy (phenolphthalein); symptomatic treatment for benign prostatic hyperplasia (terazosin); sleep improvement (diazepam); potassium supplementation to prevent hypokalemia (potassium chloride sustained-release tablets); bronchodilation and ventricular rate support (theophylline sustained-release tablets). Coronary angiography was performed on August 20 without complications. On August 28, the patient developed fever, cough with expectoration, and shortness of breath, consistent with acute bronchitis. Treatment with aztreonam (anti-infective) and ambroxol (mucolytic and expectorant) led to symptom improvement. Current condition is stable. Discharge approved by attending senior physician. Complications: None The discharge summary above indicates significant myocardial damage. Indeed it was serious — the angina had persisted for roughly ten days. This episode would cast a long shadow over everything that followed. Several years later, the patient was diagnosed with pancreatic cancer that had metastasized to the lungs. During the lung cancer phase, he began producing pink frothy sputum. By then the pancreatic cancer was already advanced and the pain was severe. Someone suggested Gamma Knife treatment to control the cancer pain. He paid a substantial sum in advance. A full course of Gamma Knife treatment required more than ten sessions. After the first few sessions, the pancreatic cancer pain did ease noticeably. But before many more sessions had passed, his coronary heart disease suddenly flared up and rapidly progressed to heart failure. He was transferred to another hospital and admitted to the cardiovascular ward. He died of heart failure in under a month. In other words, he did not die of pancreatic cancer — he died of heart failure.