Recurrent Acute Coronary Syndrome in a High-Risk Elderly Patient:A Case Report

Recurrent Acute Coronary Syndrome in a High-Risk Elderly Patient:A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Recurrent Acute Coronary Syndrome in a High-Risk Elderly Patient:A Case Report Ankit Singh This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6276928/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Acute coronary syndrome (ACS) is a critical condition requiring prompt diagnosis and intervention, particularly in high-risk patients with multiple cardiovascular risk factors. This case report highlights the challenges of managing recurrent ACS in an elderly patient with hypertension, obesity, and a history of smoking, despite optimal medical therapy. Case Presentation: A 72-year-old woman presented with recurrent retrosternal chest pain and was found to have a slightly elevated Troponin T level and deep ST-segment depression on electrocardiogram (ECG), consistent with high-risk ACS without ST elevation. Echocardiography revealed preserved left ventricular function with mild lateral hypokinesis. Coronary angiography demonstrated total occlusion of the circumflex (CX) artery, which was successfully treated with percutaneous coronary intervention (PCI) and stent implantation. The patient was discharged on dual antiplatelet therapy and remained asymptomatic at follow-up. Conclusions: This case underscores the importance of early recognition and intervention in high-risk ACS patients, even in the absence of ST elevation. Timely revascularization with stent implantation was crucial in preventing further complications and improving outcomes. The patient’s multiple risk factors, including hypertension, obesity, and smoking history, likely contributed to the development of ACS. This report emphasizes the need for aggressive risk factor modification and adherence to guideline-directed medical therapy in such patients to reduce morbidity and mortality. Cardiac & Cardiovascular Systems Acute coronary syndrome non-Q wave MI stent implantation hypertension obesity smoking elderly revascularization risk factor management Figures Figure 1 Figure 2 Background Acute coronary syndrome (ACS) remains a leading cause of morbidity and mortality worldwide, particularly in elderly patients with multiple cardiovascular risk factors. Despite advances in diagnostic and therapeutic strategies, ACS often presents diagnostic challenges, especially in the absence of ST-segment elevation. Early recognition and timely intervention are critical to improving outcomes in high-risk patients. This case report discusses a 72-year-old woman with recurrent retrosternal chest pain despite being on a full spectrum of antianginal medications. The patient had a history of hypertension, obesity, and previous smoking, all of which are significant risk factors for coronary artery disease (CAD). This case highlights the importance of aggressive management and early revascularization in high-risk ACS patients, even in the absence of ST elevation. Case Report A 72-year-old woman was referred to our institution from another hospital with ongoing, recurrent retrosternal chest pain. The pain had been present for several weeks and was described as pressure-like, radiating to the left arm, and exacerbated by physical activity. The patient had a history of hypertension for over 20 years, obesity (BMI: 32 kg/m²), and a 30-pack-year smoking history, though she had quit smoking 10 years prior. She was on a full spectrum of antianginal medications, including beta-blockers, nitrates, and calcium channel blockers. Initial evaluation at the referring hospital revealed a slightly elevated Troponin T level (0.45 ng/mL, normal < 0.01 ng/mL) and deep ST-segment depression in leads V4-V6 on electrocardiogram (ECG), suggestive of high-risk ACS without ST elevation. Echocardiography showed maintained left ventricular function (ejection fraction: 55%) with mild lateral hypokinesis. The patient was transferred to our facility for further management. Upon admission, coronary angiography revealed a total occlusion of the circumflex (CX) artery with collateral circulation from the right coronary artery. No significant lesions were observed in the left anterior descending (LAD) or right coronary arteries. Percutaneous coronary intervention (PCI) was performed, and a drug-eluting stent was successfully implanted in the CX artery. Post-procedure, the patient’s symptoms resolved, and she was discharged on dual antiplatelet therapy (aspirin and clopidogrel), a high-intensity statin, and continued antianginal medications. The discharge diagnosis was non-Q wave myocardial infarction (MI). The patient remained asymptomatic upon readmission to the referring hospital two days later for follow-up. Discussion This case underscores the importance of early recognition and intervention in high-risk ACS patients, particularly those with multiple cardiovascular risk factors. The patient’s history of hypertension, obesity, and smoking likely contributed to the development of CAD and subsequent ACS. Despite being on optimal medical therapy, she experienced recurrent symptoms, highlighting the limitations of medical management alone in high-risk patients. The role of early revascularization in ACS is well-established, particularly in patients with high-risk features such as dynamic ECG changes and elevated cardiac biomarkers. In this case, timely PCI with stent implantation was crucial in preventing further complications and improving outcomes. The absence of ST elevation on ECG did not diminish the urgency of intervention, as the patient’s clinical presentation and diagnostic findings were consistent with high-risk ACS. This case also highlights the challenges of managing ACS in elderly patients with multiple comorbidities. Aggressive risk factor modification, including smoking cessation, weight management, and blood pressure control, is essential to reducing the risk of recurrent events. Additionally, adherence to guideline-directed medical therapy, including dual antiplatelet therapy and high-intensity statins, is critical in the secondary prevention of CAD. Conclusions This case highlights the importance of timely diagnosis and intervention in high-risk ACS patients, even in the absence of ST elevation. Early revascularization with stent implantation was crucial in preventing further complications and improving outcomes. The patient’s risk factors, including hypertension, obesity, and smoking history, likely contributed to the development of ACS. This case underscores the need for aggressive management of ACS in patients with multiple risk factors to reduce morbidity and mortality. Declarations This case report was conducted in accordance with ethical guidelines for case reports. Written informed consent was obtained from the patient for publication of this case report and any accompanying images. Department of Cardiology, Semmelweis University, Budapest, Hungary( fig1 and fig 2). Ethical Considerations: Written informed consent was obtained from the patient for the publication of this case report References American Heart Association (AHA) Guidelines for the Management of Acute Coronary Syndrome. Circulation. 2021;144:e368-e454. European Society of Cardiology (ESC) Guidelines for the Management of Acute Coronary Syndromes in Patients Presenting Without Persistent ST-Segment Elevation. Eur Heart J. 2020;41:407-477. Smith SC Jr, et al. AHA/ACC Guidelines for Secondary Prevention for Patients with Coronary and Other Atherosclerotic Vascular Disease. J Am Coll Cardiol. 2011;58:2432-2446. Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6276928","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":432052860,"identity":"379d7014-4773-4fe7-a201-2973bd5b16de","order_by":0,"name":"Ankit Singh","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6ElEQVRIiWNgGAWjYFACNoYDQCjHz3D4AJAnIUOclgMHGIwlG48lgLTwEKUFqIchccPhMwYgLmEt/LPbEg9/OFOXOLPtzOdXN2oseBjYDx/dgE+LxJ1jQHfdOGzcz3N2m3XOMaDDeNLSbuC15kZ6w4EDHw7IzpxxdptxDhtQiwSPGV4t8hAtdYwb7r95ZpzzjwgtBjfSQA5jVtxw4Azz49w2IrQY3khLOHDmzGFjyYZjZsy5fRI8bIT8IncjzfhDxbE6UFQ+/pzzDchgP3wMv/eRAJsEmCRWOQgwfyBF9SgYBaNgFIwcAAA0p1jncELqbQAAAABJRU5ErkJggg==","orcid":"","institution":"Semmelweis university","correspondingAuthor":true,"prefix":"","firstName":"Ankit","middleName":"","lastName":"Singh","suffix":""}],"badges":[],"createdAt":"2025-03-21 10:57:54","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":true,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-6276928/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6276928/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":79320718,"identity":"5f32c599-001e-42a9-80fd-987e189809b1","added_by":"auto","created_at":"2025-03-27 04:24:06","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":358112,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePatients ECG\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6276928/v1/9b740433671c31809917ca25.png"},{"id":79320712,"identity":"b7248744-61cd-4200-82e3-eb6b9f61b8ec","added_by":"auto","created_at":"2025-03-27 04:24:05","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":384282,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePCI\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-6276928/v1/b2f7d677b4dad91c427ab567.png"},{"id":79321517,"identity":"f0c5d8c8-fb01-43f3-8531-ddd4904a6ce9","added_by":"auto","created_at":"2025-03-27 04:32:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":978460,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6276928/v1/fd14dfee-fbab-4b92-b49b-59c3c3d46267.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eRecurrent Acute Coronary Syndrome in a High-Risk Elderly Patient:A Case Report\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eAcute coronary syndrome (ACS) remains a leading cause of morbidity and mortality worldwide, particularly in elderly patients with multiple cardiovascular risk factors. Despite advances in diagnostic and therapeutic strategies, ACS often presents diagnostic challenges, especially in the absence of ST-segment elevation. Early recognition and timely intervention are critical to improving outcomes in high-risk patients.\u003c/p\u003e\n\u003cp\u003eThis case report discusses a 72-year-old woman with recurrent retrosternal chest pain despite being on a full spectrum of antianginal medications. The patient had a history of hypertension, obesity, and previous smoking, all of which are significant risk factors for coronary artery disease (CAD). This case highlights the importance of aggressive management and early revascularization in high-risk ACS patients, even in the absence of ST elevation.\u003c/p\u003e"},{"header":"Case Report","content":"\u003cp\u003eA 72-year-old woman was referred to our institution from another hospital with ongoing, recurrent retrosternal chest pain. The pain had been present for several weeks and was described as pressure-like, radiating to the left arm, and exacerbated by physical activity. The patient had a history of hypertension for over 20 years, obesity (BMI: 32 kg/m\u0026sup2;), and a 30-pack-year smoking history, though she had quit smoking 10 years prior. She was on a full spectrum of antianginal medications, including beta-blockers, nitrates, and calcium channel blockers.\u003c/p\u003e \u003cp\u003eInitial evaluation at the referring hospital revealed a slightly elevated Troponin T level (0.45 ng/mL, normal\u0026thinsp;\u0026lt;\u0026thinsp;0.01 ng/mL) and deep ST-segment depression in leads V4-V6 on electrocardiogram (ECG), suggestive of high-risk ACS without ST elevation. Echocardiography showed maintained left ventricular function (ejection fraction: 55%) with mild lateral hypokinesis. The patient was transferred to our facility for further management.\u003c/p\u003e \u003cp\u003eUpon admission, coronary angiography revealed a total occlusion of the circumflex (CX) artery with collateral circulation from the right coronary artery. No significant lesions were observed in the left anterior descending (LAD) or right coronary arteries. Percutaneous coronary intervention (PCI) was performed, and a drug-eluting stent was successfully implanted in the CX artery. Post-procedure, the patient\u0026rsquo;s symptoms resolved, and she was discharged on dual antiplatelet therapy (aspirin and clopidogrel), a high-intensity statin, and continued antianginal medications.\u003c/p\u003e \u003cp\u003eThe discharge diagnosis was non-Q wave myocardial infarction (MI). The patient remained asymptomatic upon readmission to the referring hospital two days later for follow-up.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis case underscores the importance of early recognition and intervention in high-risk ACS patients, particularly those with multiple cardiovascular risk factors. The patient\u0026rsquo;s history of hypertension, obesity, and smoking likely contributed to the development of CAD and subsequent ACS. Despite being on optimal medical therapy, she experienced recurrent symptoms, highlighting the limitations of medical management alone in high-risk patients.\u003c/p\u003e \u003cp\u003eThe role of early revascularization in ACS is well-established, particularly in patients with high-risk features such as dynamic ECG changes and elevated cardiac biomarkers. In this case, timely PCI with stent implantation was crucial in preventing further complications and improving outcomes. The absence of ST elevation on ECG did not diminish the urgency of intervention, as the patient\u0026rsquo;s clinical presentation and diagnostic findings were consistent with high-risk ACS.\u003c/p\u003e \u003cp\u003eThis case also highlights the challenges of managing ACS in elderly patients with multiple comorbidities. Aggressive risk factor modification, including smoking cessation, weight management, and blood pressure control, is essential to reducing the risk of recurrent events. Additionally, adherence to guideline-directed medical therapy, including dual antiplatelet therapy and high-intensity statins, is critical in the secondary prevention of CAD.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis case highlights the importance of timely diagnosis and intervention in high-risk ACS patients, even in the absence of ST elevation. Early revascularization with stent implantation was crucial in preventing further complications and improving outcomes. The patient\u0026rsquo;s risk factors, including hypertension, obesity, and smoking history, likely contributed to the development of ACS. This case underscores the need for aggressive management of ACS in patients with multiple risk factors to reduce morbidity and mortality.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003eThis case report was conducted in accordance with ethical guidelines for case reports. Written informed consent was obtained from the patient for publication of this case report and any accompanying images.\u003c/p\u003e\u003cp\u003eDepartment of Cardiology, Semmelweis University, Budapest, Hungary( fig1 and fig 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Considerations:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for the publication of this case report\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAmerican Heart Association (AHA) Guidelines for the Management of Acute Coronary Syndrome. Circulation. 2021;144:e368-e454.\u003c/li\u003e\n\u003cli\u003eEuropean Society of Cardiology (ESC) Guidelines for the Management of Acute Coronary Syndromes in Patients Presenting Without Persistent ST-Segment Elevation. Eur Heart J. 2020;41:407-477.\u003c/li\u003e\n\u003cli\u003eSmith SC Jr, et al. AHA/ACC Guidelines for Secondary Prevention for Patients with Coronary and Other Atherosclerotic Vascular Disease. J Am Coll Cardiol. 2011;58:2432-2446.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Semmelweis University","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Acute coronary syndrome, non-Q wave MI, stent implantation, hypertension, obesity, smoking, elderly, revascularization, risk factor management","lastPublishedDoi":"10.21203/rs.3.rs-6276928/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6276928/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003cbr\u003e\nAcute coronary syndrome (ACS) is a critical condition requiring prompt diagnosis and intervention, particularly in high-risk patients with multiple cardiovascular risk factors. This case report highlights the challenges of managing recurrent ACS in an elderly patient with hypertension, obesity, and a history of smoking, despite optimal medical therapy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase Presentation:\u003c/strong\u003e\u003cbr\u003e\nA 72-year-old woman presented with recurrent retrosternal chest pain and was found to have a slightly elevated Troponin T level and deep ST-segment depression on electrocardiogram (ECG), consistent with high-risk ACS without ST elevation. Echocardiography revealed preserved left ventricular function with mild lateral hypokinesis. Coronary angiography demonstrated total occlusion of the circumflex (CX) artery, which was successfully treated with percutaneous coronary intervention (PCI) and stent implantation. The patient was discharged on dual antiplatelet therapy and remained asymptomatic at follow-up.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e\u003cbr\u003e\nThis case underscores the importance of early recognition and intervention in high-risk ACS patients, even in the absence of ST elevation. Timely revascularization with stent implantation was crucial in preventing further complications and improving outcomes. The patient’s multiple risk factors, including hypertension, obesity, and smoking history, likely contributed to the development of ACS. This report emphasizes the need for aggressive risk factor modification and adherence to guideline-directed medical therapy in such patients to reduce morbidity and mortality.\u003c/p\u003e","manuscriptTitle":"Recurrent Acute Coronary Syndrome in a High-Risk Elderly Patient:A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-27 04:24:00","doi":"10.21203/rs.3.rs-6276928/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"769172d9-6ec7-4cdd-ad64-caececbbfc7d","owner":[],"postedDate":"March 27th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":46157808,"name":"Cardiac \u0026 Cardiovascular Systems"}],"tags":[],"updatedAt":"2025-03-27T04:24:00+00:00","versionOfRecord":[],"versionCreatedAt":"2025-03-27 04:24:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6276928","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6276928","identity":"rs-6276928","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}