A 55 Year Old Hypertensive Woman With Delayed Presentation of Acute Myocardial Infarction

A 55-year-old woman with a history of hypertension and hypothyroidism had admitted to the coronary care unit with complaints of central heavy chest pain for two days. She had remained untreated before the admission. She was found to have an anteroseptal myocardial infarction confirmed by troponin I and serial ECGs which are attached below.

Her vitals at the presentation were: blood pressure 160/100 mmHg, pulse 80 beats/min, normal temperature. Her initial troponin I was 7.56 ng/ml. Her hemoglobin% was 15.23 gm/dl, total leucocyte count 10,600 per microliter with 78% neutrophil, ESR 30 mm. Her lipid profile was: total cholesterol 192 mg/dl, HDL 46 mg/dl, LDL 116 mg/dl, TG 154 mg/dl. Her thyroid profile was normal on 50 mcg of thyroxine. Her serum creatinine was 0.91 mg/dl. Her RBS was 110 mg/dl, FBS 125 mg/dl, PPBS 150 mg/dl. Her HbA1C was 7.6%. Her USG whole abdomen was found to have mild hepatomegaly with fatty liver change.

She could not be given thrombolysis as she was out of the window period. She has been treated with enoxaparin 80 mg (BD) for 7 days. She has been started on dual antiplatelet (aspirin 75mg + clopidogrel 75mg), atorvastatin 20mg, olmesartan 20mg (previously taking), metoprolol 25mg (previously taking), nitroglycerine, trimetazidine 35 mg. Her repeat troponin I on the 6th day was 0.01 ng/dl.

Her husband and son who were getting treatment in India while she stressfully staying back at home alone without appropriate attention to her antihypertensives and dietary care. She had been having stable angina for quite a year; however, her TMT was reported negative 8 months back. She has a parental (father) history of premature death due to the acute coronary syndrome. Her brother has had stable angina for which he got stented after coronary angiogram a few years back. Right now after discharge, she looks clinically stable with two instances of exertional chest discomfort after the discharge.

ECG AT PRESENTATION