Our Patient
Our patient was closely followed over the next six months. He modified his habits by stopping smoking and losing weight while avoiding saturated fat and salt. He followed an aerobic exercise program while taking his medications conscientiously with no side effects. He did very well clinically and achieved control of his angina pectoris and hypertension. His serum lipids improved on appropriate medications.
Our patient did well for one year, but now comes in because his wife insisted he see the doctor. He stated his wife was worried because his symptoms recurred. He first noted chest distress with yard work and then had symptoms with one block of walking. His physical examination revealed a blood pressure of 110/70 mmHg and a fourth heart sound at the apex. His laboratory work was normal.
Our patient was advised to have a coronary angiogram to define his coronary anatomy in the setting of progressive symptoms. Although not necessary in our patient, a stress imaging study could provide information regarding the location and extent of his myocardial ischemia.
Imaging techniques to assess location of myocardial ischemia include several methods, such as radionuclide perfusion scans, echocardiography, and magnetic resonance imaging. The ischemic zones can be delineated by exercise or dobutamine or coronary arteriolar vasodilators such as adenosine or dipyridamole.
Our patient's stress echocardiogram was carried out by administering dobutamine. Dobutamine is a beta adrenergic agonist that increases heart rate and contractility. This allows the assessment of stress induced changes in wall motion and wall thickness. The normal response to stress is for wall motion to become hyperkinetic with increased systolic thickening and decreased cavity size.