A 73-year-old obese female ex-smoker with chronic angina, persistent atrial fibrillation, coronary artery disease with coronary artery bypass graft surgery six years ago, type 2 diabetes mellitus, asthma, peripheral arterial disease (PAD) and a history of deep venous thrombosis following knee replacement surgery one year ago, presents to the emergency room with complaints of substernal chest discomfort at rest lasting six hours in duration and associated with diaphoresis and nausea.

The electrocardiogram (ECG) demonstrated atrial fibrillation with a controlled ventricular response and nonspecific ST-T abnormalities not significantly changed from an old ECG one year earlier. The first troponin level was minimally increased. INR was therapeutic at 2.5. The patient's chest discomfort resolved after sublingual nitroglycerin x2; however, she subsequently became transiently hypotensive. Her body mass index (BMI) is 39. Examination is significant for central obesity.

Three months earlier, she had undergone a pharmacologic stress MIBI. She was unable to exercise on a treadmill due to her PAD. Myocardial perfusion imaging was deemed technically inadequate due to breast attenuation. There was a small, partially reversible defect of mild intensity in the anteroapical segments. Afterward, her cardiologist added ranolazine 500 mg twice daily to her medical regimen, which also included aspirin 81mg daily, coumadin 3 mg daily, atorvastatin 40 mg daily, metoprolol succinate 50 mg daily, and enalapril 10 mg daily.