Angina due to high heart rate.

A 65-year-old female patient presented with a 6-week history of effort-related angina (Canadian Cardiovascular Society Class II). She gave no past cardiac history and was not on any medications. She is a lifelong non-smoker.

On examination, she was in sinus rhythm, with a heart rate of 76 b.p.m. and a blood pressure of 135/85 mmHg. Investigations revealed that she had a normal full blood count, normal renal and liver function, and normal thyroid function. Her total cholesterol was 200 mg/dL, low-density lipoprotein 110 mg/dL, high-density lipoprotein 50 mg/dL, and glucose 80 mg/dL. The ECG showed an anterior T-wave inversion in V3 and V4. The 2D echo showed a mildly impaired left ventricular function with anterior hypokinesia and an ejection fraction of 40%.

What investigations do you want?

This is a new presentation of angina in a patient that has been shown to have T-wave inversion across the front of the chest and impaired left ventricular dysfunction; therefore, it is important to define the physiology and anatomy to stratify treatment. A stress echo was arranged, which showed an area of reversible ischaemia under stress in the anterior wall. A coronary CT angiography showed an occluded mid-left anterior descending coronary artery.

How should she be treated?

She was started on aspirin 75 mg once daily and atorvastatin 20 mg once daily. In addition, she was started on the beta-blocker metoprolol 25 mg twice daily. Metoprolol was started as she gave a history of effort angina, with a high heart rate and a normal blood pressure. The atorvastatin to correct the elevated low-density lipoprotein and aspirin is generally used in stable angina.

One month later, there was no improvement because she was still complaining of angina. On examination, she was in sinus rhythm, with a heart rate of 72 b.p.m. and a blood pressure of 110/70 mmHg.

What should be done next?

Ivabradine was cautiously introduced at a dose of 2.5 mg twice daily. A further increase in the dose of metoprolol was not warranted as her blood pressure was low.,

Two weeks later, she was feeling much better, complaining only of occasional angina; heart rate was 62 b.p.m. and blood pressure 120/74 mmHg.

Funding

The authors didn't receive any financial support in terms of honorarium by Servier for the articles.

Conflict of interest: K.F. has received fees, honoraria and travel expenses from Servier, AstraZeneca, Broadview Ventures, CellAegis, Celixir, Taurx and UCB. He is a director of Vesalius Trials Ltd.