Case presentation 1
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A 61-year-old man presented with recurrent episodes of exertional chest pain starting approximately 4 months prior. The pain was described as deep, pressure-like sensation, rated to be 4 on 10-point scale. The patient reported radiation of pain to left shoulder, with relief after few minutes of rest. The patient's medical history included hypertension, hyperlipidemia, hypothyroidism, gastroesophageal reflux disease (GERD), and coronary artery disease (CAD). The patient underwent percutaneous coronary intervention (PCI) with placement of drug eluting stents in his distal right coronary artery (RCA) and proximal left anterior descending artery 10 years earlier. For the current illness, a recent electrocardiogram (ECG), conducted 3 months prior, indicated no changes from baseline and negative cardiac enzyme assays. Similarly, exercise stress test found no evidence of stress-induced myocardial ischemia.
The patient's medications included aspirin 81 mg, clopidogrel 75 mg, irbesartan 300 mg, atorvastatin 80 mg, atenolol 25 mg, amlodipine 5 mg, levothyroxine 88 mcg, and multivitamins, all taken daily. The patient also started taking pantoprazole 40 mg orally daily x 4 months after being diagnosed with GERD.
With his current presentation, vital signs were normal and he was normotensive, with regular heart rhythm and normal rate with no murmurs, rubs, or gallops. All other lab and ECG evaluations were also found to be normal. Based on these examinations, the authors suspected pantoprazole to be causative of the patient's chest pain. Pantoprazole was discontinued and the patient was initiated on ranitidine 150 mg orally twice daily for GERD. Upon follow-up, the patient reported symptoms to have resolved within a few days of pantoprazole discontinuation, with no recurrence at 8 months of follow-up.
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Case presentation 2
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A 73-year-old woman presented for coronary angiography to evaluate anomalous RCA due to refractory exertional angina. The patient's medical history included hypertension, hyperlipidemia, CAD, hypothyroidism, arthritis, and diet-controlled diabetes mellitus type 2. Two months prior to presentation, the patient started experiencing constant, nonradiating, pressure-like chest pain in the middle of her chest, lasting for 3-5 minutes, rated as severity of 8 on a 10-point pain scale. The pain was aggravated by exertion and relieved with sublingual nitroglycerin. The patient underwent coronary angiography and PCI after coronary computed tomography (CT) scan found obstructive proximal left circumflex artery stenosis and calcified anomalous RCA. Despite the PCI, chest pain symptoms improved yet continued. An ECG was found to be normal, with no evidence of ischemic changes.
The patients medications included aspirin 81 mg, prasugrel 10 mg, pravastatin 40 mg, metoprolol succinate 25 mg, levothyroxine 100 mcg, amlodipine 10 mg, and esomeprazole 40 mg daily, omega-3 fatty acid-vitamin E 1000 mg TID, and nitroglycerin as needed. Her cardiovascular examination, as well as laboratory data were found to be normal. Based on angiographic findings, the authors suspected omeprazole to be the causative agent of the angina-like symptoms. The patient's esomeprazole was discontinued and switched to ranitidine 150 mg twice daily due to use of dual antiplatelet therapy. After a one-week follow-up, the patient was reported to be symptom free, which was also confirmed at an 8 month follow-up.
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