A 52 years old male taking treatment for hypertension and Dyslipidaemia. Nebilol 5,atorvastatin 20,Telma H 40 for couple of years with good control. He is nondiabetic and to some extend overwt. Not a smoker but take alcohol on occasions. For the last 3 months he has chest pain but as per the severity is concerned he has consulted now. As per the description he had mild pain sometimes go away but not much relation to food or activity.Following are the ecg and reports.Your diagnosis and line of treatment :

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ecg S/o sinus rhythm with complete Rbbb, No Significant St-t changes... 1.whether this ecg was taken during chest pain? 2.Does the h/o chest pain consistent with Cardiac origin? ?Stable Angina Risk factors: Male gender Age Syst Htn Dyslipidaemia Alchoholic Advice 2d echo, if normal can proceed for TMT for exercise induced Ischaemia Blood sugars,S.Tsh,s.uric acid,BMI Treatment LSM, DASH diet Nebivilol and telma h to be continued if bp is under 130/80 Atorvas dosage to be increased to 40 mg Add aspirin 75 mg considering risk factors,calculating 10 yr CV risk...

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Let the cardiac status be fully investigated. But the clinical presentation does not fit in chest pain due to cardiogenic origin. I find it is atorvastatin 20 mg which the patient is taking for the last many years is the culprit.Atorvastatin induced myopathic chestpain ,low backache and calf muscle pain is commonly seen in clinical practice. Just switch over to 10 or 5 mg Rosuvastatin depending upon lipid profile will help the patient along with a . Tramodol paracetamol combination

Urine sugar present. Fasting blood sugar is slightly above normal but below 126mg. please do glycosylated hb. Or glucoes tolerance test to rule out possibility of diabetes. Start aspirin clopidogrel . Nitroglycerin Do angiography. Then dignosis of IHD will be complete. Reduce wt and stop alcohol.

H/o chest pain for three months and ecg showing Rt BBB and perhaps old inferior wall infarction (though q is only in 3 but no r in avf and stunted r in 2).If it is recent conversion to Rt BBB,it is almost certainly IHD probably RCA block. Pt was sent for cardiac workout, let us see what will come out?

ECG sx of RBBB Echo ,HBA1c, Blood sugar, lipid profile should be done. Angiography should be planned which will decide further management. Continue medicine that Pt is taking. n add ecosprin 75 mg along with nitrate

ECG shows RBBB, needs stress test & 2D ECHO to assess his cardiac status, Lipid profile, S.Uric acid, SGPT, S. Creatinine, CBC, Thyroid functions HBA1c FBS to be done for further evaluation

cardiac angiogram & ecocardiography is must with other investigations
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He is getting angina ..and has already risk factorsof HTN,Dyslipedemia. His ECG shows RBBB,.His previous ECG could be compared to new one.He needs ECHO,TMT,cardiac stress test and angio. Nitrate,or Ranolazine 500mg bd may be added to treatment

Myocardial ischemia ? Ecosprin 150 mg OD . Angised SOS Atorvastatin 20 mg BD . 2 D echo Angiography suggested LSM &DASH

Old IWMI RBBB 1st Echo than Tmt higher chances of CAD

tropi and tropt 2decho for wall motion abnormality

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