How should a 54-year-old patient with a complex medical history including bicuspid aortic valve, nonobstructive CAD, and multiple comorbidities be managed after presenting with symptoms and diagnostic findings consistent with NSTEMI?

Cardiology Consultation SOAP Note

Subjective

Patient: 54-year-old male, known to Dr. Salvaggio, presenting with midline chest pain described as pressure radiating to left jaw and bilateral upper extremities.

History of Present Illness: Presented to LGMC on 7/15/25 with chest pain. Workup revealed mildly elevated troponin (0.052, rising to 0.08). EKG showed sinus bradycardia with inverted T waves in inferior leads. CXR without abnormalities. Consulted for NSTEMI management.

Past Medical History: Bicuspid aortic valve, nonobstructive CAD, HTN, HLD, PFO (with closure), VHD, NASH, COPD, OSA, CVA, seizure disorder, GERD, BPH, depression, anxiety, adenoma of ampulla of vater.

Past Surgical History: Eye removal, LHC, TEE, PFO closure, loop recorder placement.

Family History: Father and mother with HTN.

Social History: Ex-smoker.

Objective

Vital Signs: [Include current vital signs]

Cardiovascular Exam: [Include pertinent physical exam findings]

Previous Cardiac Diagnostics:

• Echocardiogram (6/18/25): Normal LV size and function, EF 55%, normal diastolic function. Bicuspid aortic valve with mild calcification. Dilated aortic root (4.1 cm) and ascending aorta (4.0 cm). Mild-moderate (1-2+) aortic regurgitation. Mild tricuspid regurgitation. PFO closure device noted. PASP 19 mmHg.
• Carotid US (6/18/25): 1-39% stenosis in proximal right and left internal carotid arteries.
• TEE (10/29/24): Normal LV size and function, EF 55-60%. Bicuspid aortic valve without stenosis. Moderate aortic regurgitation. St. Jude PFO closure device across atrial septum.
• LHC (10/29/24): LM-Normal, LAD-40% mid (IFR 0.93), Circumflex-60% (IFR 1), RCA-50% (IFR 1), EDP-17, Wedge 15, AVA 2.38 cm², Mean Gradient 13, no AI on root angiogram.

Labs: Troponin 0.052, rising to 0.08.

EKG: Sinus bradycardia with inverted T waves in inferior leads.

CXR: No abnormalities noted.

Assessment

1. NSTEMI: Intermediate-risk based on elevated troponin, T-wave inversions, and characteristic chest pain. Risk factors include age, prior CAD, and multiple comorbidities 1.

2. Bicuspid aortic valve with moderate aortic regurgitation and dilated aortic root (4.1 cm) and ascending aorta (4.0 cm).

3. Non-obstructive CAD per previous catheterization with physiologically non-significant lesions (all IFR > 0.89).

4. Multiple cardiovascular risk factors: HTN, HLD, prior CVA, OSA.

5. Multiple comorbidities: COPD, NASH, seizure disorder, GERD, BPH, depression, anxiety, adenoma of ampulla of vater.

Plan

For NSTEMI management:

1. Antiplatelet therapy:

   • Initiate dual antiplatelet therapy with aspirin 325 mg loading dose followed by 81 mg daily and clopidogrel 300 mg loading dose followed by 75 mg daily 2.
   • Monitor for bleeding risk given multiple comorbidities.

2. Anticoagulation:

   • Start enoxaparin 1 mg/kg SC q12h (adjust for renal function if needed).
   • Consider transition to unfractionated heparin if invasive strategy planned.

3. Anti-ischemic therapy:

   • Continue or initiate beta-blocker (metoprolol) if no contraindications.
   • Nitrates as needed for chest pain.
   • High-intensity statin (atorvastatin 80 mg daily).

4. Invasive strategy:

   • Recommend early invasive strategy (within 24-48 hours) given intermediate risk NSTEMI with multiple risk factors 1.
   • Previous catheterization showed non-obstructive CAD, but repeat evaluation is warranted given new acute coronary syndrome.

5. Monitoring:

   • Continuous cardiac monitoring.
   • Serial troponin measurements.
   • Repeat EKG with any recurrent symptoms.

6. For bicuspid aortic valve and aortic dilation:

   • Continue beta-blocker therapy which will also help with aortic root protection.
   • Schedule follow-up echocardiogram in 6 months to monitor aortic dimensions.
   • Consider cardiothoracic surgery consultation if aortic dimensions progress.

7. Secondary prevention:

   • Optimize blood pressure control.
   • Optimize lipid management.
   • Smoking cessation reinforcement.
   • Diabetes screening and management if applicable.
   • Cardiac rehabilitation referral after discharge.

8. Follow-up:

   • Cardiology follow-up in 2 weeks post-discharge.
   • Repeat echocardiogram in 6 months to assess LV function and aortic dimensions.

This management plan addresses both the acute NSTEMI and the patient's underlying cardiac conditions, with special attention to his bicuspid aortic valve and aortic dilation which require ongoing monitoring and management.