Treatment of a 75-year-old man with diabetes mellitus and angina pectoris

A 75-year-old former dentist was admitted to our department for evaluation of chronic angina pectoris. The patient’s medical history included metabolic syndrome with obesity, long-standing type 2 diabetes mellitus, hypertension, dyslipidemia, a family history of premature coronary artery disease, and sleep apnea syndrome. He was treated with 100 mg of aspirin once daily, 50 mg of metoprolol (Lopressor, Toprol XL) once daily, 5 mg of felodipine (Plendil) once daily, 25 mg of chlorthalidone (Hygroton) once daily, 20 mg of simvastatin (Zocor) once daily, and 40 mg of gliclazide (Diamicron) twice daily. One year earlier, an echocardiogram taken before orthopedic surgery showed an inferior scar and slightly impaired left ventricular systolic function. At that time, the patient was asymptomatic. However, 10 months later, he began to have progressive angina pectoris, specifically when going for a walk, and felt increasingly exhausted and depressed. Stress echocardiography showed the known inferolateral hypokinesia with good contraction of the other parts of the ventricle at rest, but marked hypokinesia of the anterolateral wall with dilatation of the left ventricle and decrease of left ventricular function from 45% to 35% during stress.

Coronary angiography subsequently showed 3-vessel disease with occlusion of the median right coronary artery, a highly stenotic proximal left anterior descending coronary artery with additional significant stenoses in the median and apical parts of the vessel, and an occluded second marginal branch of the circumflex coronary artery. The patient underwent percutaneous coronary intervention (PCI) of the left anterior descending artery and the median right coronary artery, with deployment of 3 and 1 bare metal stents, respectively. He was discharged with a prescription for additional clopidogrel (Plavix), 75 mg once daily, for 6 months.

The patient was free of symptoms for 3 months, when he presented with new-onset chest pain on light physical activity. Repeated coronary angiography showed significant in-stent restenosis of the median right coronary artery. Another PCI with deployment of a drug-eluting stent was performed, and the patient was discharged. Six months later, single photon emission computed tomography showed an inferolateral scar without ischemia and only slightly impaired left ventricular function. At present, the patient is well and does not have any symptoms of chronic angina pectoris.