Mr. B is an 82-year-old Caucasian male presenting to the emergency department with retrosternal chest pain. He states this has been present for many years. He came in today because his chest discomfort was slightly more than before.

His cardiovascular comorbidities include remote history of percutaneous coronary intervention with stent implantation, paroxysmal atrial fibrillation, hypertension, hyperlipidemia.

His non-cardiovascular comorbidities include chronic obstructive pulmonary disease, diabetes mellitus, chronic kidney disease stage 3A.

Pertinent Social History: Mr. B resides at a nursing home because of decreasing physical function and minimal family support.

Current medications include carvedilol (25mg BID), aspirin (81mg), losartan (50mg BID), apixaban (5mg BID), ipratropium-albuterol (4 puffs daily), fish oil (2 capsules daily).

Physical Exam:

Thin-appearing male with a pulse of 75 bpm, blood pressure of 110/80 mmHg, and body-mass-index of 19. Cardiac exam revealed an irregularly irregular rhythm without murmurs. Lungs were clear. Neurological exam: demonstrated no abnormality in motor function.

Electrocardiogram: Atrial fibrillation with a ventricular rate 65-80 bpm and no ST-T segment changes. Echocardiogram: Ejection fraction 55%, mild mitral regurgitation, normal right ventricular systolic pressure. The most recent pulmonary function test was without any significant obstructive defects.

His peak troponin was 1.1 ng/ml. He was diagnosed as having a NSTEMI.

The following two questions are based on the clinical vignette.

Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Prevention, Valvular Heart Disease, Atrial Fibrillation/Supraventricular Arrhythmias, Interventions and ACS, Interventions and Structural Heart Disease, Hypertension, Mitral Regurgitation

Keywords: Geriatrics, Atrial Fibrillation, Blood Pressure, Myocardial Infarction, Body Mass Index, Aspirin, Stroke Volume, Mitral Valve Insufficiency, Chest Pain, Hypertension, Percutaneous Coronary Intervention, Pulmonary Disease, Chronic Obstructive, Diabetes Mellitus, Emergency Service, Hospital, Respiratory Function Tests, Electrocardiography, Renal Insufficiency, Chronic, Albuterol, Stents, Acute Coronary Syndrome

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