Zafar Ul Islam, Zulfiqar Ali Kango.
Normal Exercise Tolerance Test in a patient with Severe Left Main Coronary Artery Disease.
J Coll Physicians Surg Pak Jan ;14(3):178-9.

A 31 years old soldier reported in emergency reception (ER) with history of left sided atypical chest pain since one day. Smoked 5 cigarettes a day for last 5 years. There was no ischemic heart disease, hypertension or diabetes in the personal or family history. Two electrocardiograms recorded at ER showed no abnormality apart from hyper acute T waves. After intramascular injection of diclofenac sodium 75 mg at emergency reception he was admitted in CCU (coronary care unit) and treated as a case of unstable angina pectoris. Treatment included intravenous nitrates, heparin @ 1000 iu/hr, oral metoprolol 100 mg OD and disprin 150 mg OD. Serial electrocardiograms recorded during three consecutive days in CCU showed no change from the initial ECG (electrocardiogram). Cardiac enzymes showed a rise in CPK (creatinine phosphokinase) but there was no meaningful rise in CK-MB or LDH on three consecutive days. Patient developed low grade fever on second and third day of his stay in CCU along with mild leukocytic response. His random blood sugar, total cholesterol and lipoproteins, Triglycerides were within normal limits with mild neutrophilia. X-ray chest was also normal. Echocardiogram showed normal sized cardiac chambers with ejection fraction 70 percent, fractional shortening 35% and no evidence of regional wall motion abnormality. On fourth day a graded ETT was planned as per Bruce protocol. He achieved 85% of target heart rate in stage 4 after 12 minutes. There was no ischemic electrocardiogram change or arrhythmia during exercise and recovery period. As per ACC/AHA guidelines, radioisotope thallium scan or coronary angiogram was not performed. Patient was discharged with reassurance and advise to quit smoking and prevent other risk factors. After 5 days his dead body was brought to CMH, Multan. There was a short history of epigastric discomfort and chest pain followed by collapse and death in a private clinic at Mian Chunu. An autopsy was carried out that disclosed critical coronary artery disease. It was found that left main coronary artery had atheromatous plaque occluding 95% of lumen with thrombus inside, totally occluding the vessel. Left anterior descending artery (LAD) was 50% blocked in the middle and left circumflex artery (LCx) had 30% disease. There was an extensive area of myocardial infarction on gross and microscopic examination.

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