Detailed Treatment Process
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The patient owned a property in the suburban fringe area. His wife had passed away several years earlier, so he sometimes lived there alone. One day he experienced his first episode of angina. He had no idea what it was, only that he felt a heavy, painful pressure in his chest that lasted for days. When the discomfort became unbearable, he went to the nearby community hospital. The community hospital performed an electrocardiogram and prescribed medications such as enteric-coated aspirin. These were slow-acting agents, whereas the standard emergency treatment for an acute ischemic attack is sublingual nitroglycerin. However, the community hospital doctors did not prescribe nitroglycerin. After taking the medication, his chest pain persisted. Why didn’t he return to the city for care? The only bus route from that area to the city was frequently blocked by container trucks, with a single intersection often jammed for more than half an hour. The journey took several hours and offered no guarantee of a seat. Now over 70 years old and in the midst of an angina attack, he lacked the strength to make the trip alone. He also did not want to ask his children for help. So he simply endured the pain locally. Several days later he returned to the community hospital and was again given slow-acting drugs such as aspirin. The pain continued, and he kept enduring it. While out shopping for groceries one day, a neighbor noticed his ashen face and learned what was happening. This neighbor himself had a history of angina. More importantly, his son was a doctor at the community hospital. The neighbor immediately took the patient to see his son and told him, “Give him the same medication you give me.” Without hesitation, the son wrote “nitroglycerin” on the prescription. This time the doctor skipped the lengthy notes and simply prescribed the drug. After taking nitroglycerin, the patient’s chest tightness and pain resolved rapidly. He regained enough strength to take the bus back to his home in the city, which was located right next to a major hospital. He was admitted immediately. The following is the discharge summary: Ward: CCU Gender: Male Age: 77 years Admission date: August 10 Discharge date: September 7 Length of stay: 28 days Outpatient diagnosis: Coronary atherosclerotic heart disease; unstable angina; arrhythmia; sinus bradycardia; chronic heart failure NYHA Class III; essential hypertension grade 3 (very high risk); type 2 diabetes mellitus; prostatic hyperplasia Admission diagnosis: Coronary atherosclerotic heart disease; unstable angina; arrhythmia; sinus bradycardia; chronic heart failure NYHA Class III; essential hypertension grade 3 (very high risk); type 2 diabetes mellitus; prostatic hyperplasia Discharge diagnosis: Coronary atherosclerotic heart disease; unstable angina; arrhythmia: sinus bradycardia; chronic heart failure NYHA Class III; essential hypertension grade 3 (very high risk); type 2 diabetes mellitus; acute bronchitis; prostatic hyperplasia; mild cholecystitis Main symptoms and signs on admission: A 77-year-old male was admitted with “paroxysmal chest tightness and chest pain for two weeks.” Physical examination: Alert, normal respiration, BP 126/68 mmHg, HR 58 bpm, regular rhythm. Cardiac monitoring showed sinus rhythm. Breath sounds were coarse in both lungs with scattered fine crackles in the right lower lung. Abdomen soft, no tenderness. No edema in lower limbs. Normal muscle strength in all four extremities, no pathological reflexes. 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; neutrophil percentage 56.2%; uric acid 502 μmol/L; urea 6.6 mmol/L; creatinine 105 μmol/L; BNP 88 pg/ml; HbA1c 8.5%; D-dimer 94 μg/L; fibrinogen 3.2 g/L; total bilirubin 14 μmol/L; albumin 34 g/L; γ-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; ALT 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; urine ketones negative; cardiac enzymes negative; coagulation normal; stool routine and occult blood negative. Special investigations and consultations (with dates and report numbers): Electrocardiogram: sinus bradycardia, left ventricular hypertrophy with ST-T changes, left atrial overload, abnormal Q waves in inferior leads. Chest CT on August 19: increased lung markings, calcified focus in right upper lobe, bilateral pleural effusion. Chest X-ray on September 1: increased lung markings, cardiothoracic ratio 0.52. 24-hour Holter: sinus rhythm (42–75 bpm), 5 atrial premature beats, no ventricular premature beats, maximum ischemic ST depression 0.20 mV. Ultrasound: slightly coarse liver parenchyma echo, mild cholecystitis. Echocardiogram: enlarged left atrium and left ventricle, degenerative aortic valve with mild regurgitation, mild mitral regurgitation, normal left ventricular function. Sputum culture: Neisseria and alpha-hemolytic streptococci. Coronary angiography on August 20: 50% stenosis of left main, 95% stenosis of mid left anterior descending, 90% stenosis of mid circumflex, 40–50% proximal and 98% mid right coronary artery stenosis. Coronary artery bypass grafting was recommended. Renal artery angiography: 60–70% stenosis at origin of right renal artery, left renal artery normal. Clinical course and treatment outcome (including procedure names, dates, transfusions, and resuscitations): After admission, the patient completed relevant examinations and received anticoagulation and antiplatelet therapy (clopidogrel), blood pressure control and ventricular remodeling improvement (valsartan), glucose control (glimepiride), coronary vasodilation (isosorbide dinitrate, isosorbide mononitrate), diuresis (furosemide), aldosterone antagonism (spironolactone), plaque stabilization (simvastatin), myocardial nutrition and inotropic support (sodium fructose diphosphate, dopamine), laxative (phenolphthalein), symptomatic treatment for prostatic hyperplasia (terazosin), sleep improvement (diazepam), potassium supplementation (potassium chloride sustained-release tablets), bronchodilation and heart rate support (theophylline sustained-release tablets), among other symptomatic measures. Coronary angiography was performed on August 20 and went smoothly. On August 28 he developed fever, cough with sputum, and shortness of breath. Acute bronchitis was diagnosed and treated with aztreonam for infection and ambroxol for expectoration. Symptoms improved. The patient’s condition is now stable. With approval from the attending physician, discharge is granted. Complications: None.
The discharge summary shows that the myocardial damage was quite severe. It was indeed serious, because the angina had already lasted about 10 days. This incident laid the groundwork for later problems. Several years later, the patient was diagnosed with pancreatic cancer that had metastasized to the lungs, resulting in lung cancer. At the lung cancer stage he produced red frothy sputum. By then the pancreatic cancer was advanced and the cancer pain was severe. Someone suggested Gamma Knife radiosurgery to control the pain, and he paid a substantial sum in advance. A full course of Gamma Knife involved more than ten sessions. After the first few sessions, the pancreatic cancer pain did ease somewhat. But after only a few more sessions, 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. Less than a month later, he died of heart failure. In other words, he did not die of pancreatic cancer, but of heart failure.