Case Report
A 65-year-old female patient with a history of hypertension came to OPD in S.M.B.B. Trauma Centre, Karachi with the complaint of chest pain and shortness of breath. According to patient she was in usual state when suddenly she started having chest pain that was sharp, high in intensity and radiates to left arm, worsens by exertion and relieved by relaxation and medication. She also has shortness of breath. After taking history and examination, the patient was found to have paroxysmal nocturnal dyspnea and orthopnea. Her pulse was 68 and her blood pressure was 140/100. Past medical history revealed she had hypertension, cholelithiasis and dyslipidemia. In 2008, she was diagnosed with class II angina according to CCS (Canadian Cardiovascular Society) grading. Coronary angiography was carried out in 2008 which revealed triple vessel coronary artery disease and normal Left ventricular ejection fraction (LVEF). She underwent coronary artery bypass graft surgery in 2009. In cabg, long saphenous vein (lsv) was harvested from the right thigh and left leg. The pieces were joined to create appropriate length. Left internal mammary artery (LIMA) was 1.5mm, excellent flow. Lad 1.75mm clean and intramyocardial. Left anterior descending artery (LAD) was grafted with LIMA while obtuse marginal (OM) was grafted with reversed saphenous vein graft. In 2013, Myocardial perfusion imaging (MIBI) was done using 8mCi of Tc-99m isotope which revealed normal findings. Transthoracic echocardiography and doppler study were done in June 2022 which revealed normal size LV, EF 55% and diastolic dysfunction grade I. Graft study was done which revealed left main (LM) and right coronary artery (RCA) were normal, left circumflex artery (LCX) with mild stenosis and obtuse marginal with subtotal stenosis and severe ostial stenosis of LAD was observed in proximal portion which can be seen in figure 1. The patient was found to have ischemic heart disease and coronary syndrome with increased risk of myocardial infarction. The patient is currently on drug therapy of risek, ascard, lipiget, flexiflow, monis, cancos and sofvase. Echocardiogram and ECG of the patient are shown in figure 2 and figure 3 respectively.