Cardiology OP Clinic Letter

Cardiologist Diagnosis Hypertensive heart disease. Left ventricular hypertrophy. Chest X-ray, 25th October 2024. Hyperlipidaemia. Type 2 diabetes mellitus. Medications Lisinopril 10 mg once a day Amlodipine 5 mg once a day Atorvastatin 40 mg once a day Metformin 500 mg twice a day Summary Plan Initiate lifestyle modifications including diet and exercise. Up-titrate Lisinopril to 20 mg once a day. Order repeat lipid profile in 3 months. Referral to dietician. Schedule follow-up appointment in 6 weeks. I met this 68-year-old female in Cardiology clinic today. She was referred for evaluation of new onset exertional chest pain and shortness of breath, raising concern for coronary artery disease. The patient has noticed progressively worsening exertional chest pain over the last three months. The pain is described as a heavy pressure in her chest, radiating to her left arm, typically occurring with moderate exertion such as walking up a flight of stairs. It subsides with rest within five minutes. She has also noticed associated shortness of breath with these episodes. She has not noticed palpitations, dizziness, or syncope. Her symptoms are aggravated by physical activity and alleviated by rest. Her significant past medical conditions include hypertension, diagnosed in 2010, managed with Lisinopril and Amlodipine. She was diagnosed with hyperlipidaemia in 2015 and takes Atorvastatin. Type 2 diabetes mellitus was diagnosed in 2018 and is managed with Metformin. The patient is a non-smoker and reports occasional alcohol consumption, approximately 2 units per week. She is retired from her job as a primary school teacher and lives alone in a ground floor flat. Her father passed away at age 65 due to a myocardial infarction. Her mother has hypertension and type 2 diabetes. She has no other significant family history. On physical examination, her blood pressure was 145/88 mmHg, heart rate 72 bpm, respiratory rate 16 breaths per minute, and oxygen saturation 98% on room air. Weight was 78 kg, which, with height 160 cm, gives BMI 30.5 kg/sqm. Cardiovascular examination revealed a regular pulse, no murmurs or rubs, and normal heart sounds. Lung fields were clear to auscultation bilaterally. There was no peripheral oedema. Resting ECG shows sinus rhythm at 70 bpm, with a normal QRS axis and duration. ST segment and T-wave morphology are normal and the corrected QT interval is 420 ms. A lipid profile on 28th October 2024 showed non-HDL and LDL cholesterol levels of 3.8 mmol/L and 2.5 mmol/L respectively. A recent chest X-ray on 25th October 2024 showed evidence of left ventricular hypertrophy but no overt signs of heart failure or acute pulmonary pathology. Laboratory results showed HbA1c 7.2%. The primary differential diagnosis is stable angina pectoris due to coronary artery disease, given her classic exertional chest pain, cardiovascular risk factors, and positive family history. The plan is to initiate aggressive lifestyle modifications, optimise her antihypertensive and lipid-lowering therapy, and consider further investigation with a stress echocardiogram or cardiac CT angiography to assess for obstructive coronary artery disease. Another possibility is microvascular angina, which can present with similar symptoms, particularly in diabetic patients. Management for this would involve symptom control and risk factor modification. Non-cardiac causes such as musculoskeletal pain or anxiety are less likely given the typical nature of her symptoms but should be kept in mind. We discussed the importance of managing her blood pressure, cholesterol, and blood sugar levels diligently to reduce her cardiovascular risk. We also reviewed the expected outcomes of these interventions, which should include a reduction in her chest pain and improved exercise tolerance. Potential challenges include adherence to lifestyle changes and medication, and she was provided with resources to support these efforts. I have advised the patient to live life completely normally. I have scheduled a follow-up appointment in 6 weeks to review her progress and the results of any further investigations. She has been provided with information regarding a heart-healthy diet and the benefits of regular exercise.