In this article you will find a complete and realistic discharge summary of an acute coronary syndrome in the form of an inferoposterior ST-elevation myocardial infarction (STEMI). The case is oriented to the clinical routine of German hospitals and covers the entire inpatient course – from admission through diagnostics and cardiac catheterization to discharge.

Dear Colleague,

below we report on the inpatient treatment of the above-mentioned patient

Diagnoses

Primary diagnosis:

• Acute coronary syndrome in the form of an inferoposterior ST-elevation myocardial infarction (STEMI) due to thrombotic high-grade stenosis of the mid right coronary artery (Mid RCA), successfully treated by primary percutaneous coronary intervention (PCI) and implantation of a drug-eluting stent (DES).

Secondary diagnoses:

• Arterial hypertension
• Type 2 diabetes mellitus
• Benign prostatic hyperplasia
• Obesity grade I (BMI 28.7 kg/m²)

History

The 57-year-old patient presented emergently on 02.07.2025 due to suddenly occurring, persistent retrosternal chest pain since the early morning hours.

The symptoms had started abruptly during an emotional stress when the patient accompanied his grandson in the ambulance to the hospital after a seizure.
He described the pain as severe pressure and tightness behind the sternum with an intensity of 8/10.
The pain was constant and radiated to the left lower jaw and the neck.

Accompanying symptoms reported by the patient included dyspnea, dizziness, nausea, cold sweats, pallor, and pronounced fear of dying.

For about six weeks prior, exertional chest discomfort consistent with angina pectoris had occurred, especially when climbing stairs, brisk walking approximately 150 meters, or carrying heavy loads. The complaints had each time resolved spontaneously at rest. No medication therapy had been started to date.

Fever, cough, palpitations, syncope, vomiting, position- or respiration-dependent increase in pain, and thoracic tenderness were denied.

Relevant past medical history includes a known type 2 diabetes mellitus for eight years, arterial hypertension, and benign prostatic hyperplasia.

As chronic medication, the patient took Ramipril 5 mg once daily, Metoprolol succinate 95 mg once daily, Hydrochlorothiazide 12.5 mg once daily, Metformin 500 mg 1-0-1, Tamsulosin 0.4 mg once daily, and Dutasteride 0.5 mg once daily.

There is a contact allergy to rubber gloves and a metamizole allergy with generalized exanthem and dyspnea.

The patient is a former smoker (approx. 10 pack-years, nicotine abstinence for three years). Alcohol is consumed as one to two glasses of beer daily. Drug use was denied.

Physical examination

On admission he was awake and oriented but visibly suffering from pain and anxious, in a reduced general condition.

Height: 176 cm
Weight: 89 kg
BMI: 28.7 kg/m²

Vital signs on admission (02.07.2025):

• Blood pressure: 100/60 mmHg
• Heart rate: 43/min (bradycardic)
• Respiratory rate: 24/min
• Oxygen saturation: 93 % on room air
• Body temperature: 36.7 °C

The patient was diaphoretic and pale. Skin was cool but without cyanosis.

Lung auscultation revealed bilateral vesicular breath sounds without crackles or wheeze.

Cardiac auscultation showed a regular bradycardia without pathological murmurs.

The abdomen was soft, non-tender, and without guarding. Bowel sounds were normal.

There were no peripheral edema, no jugular venous distension, and no clinical signs of deep vein thrombosis.

Neurologically there was no focal deficit. The patient was fully oriented and cooperative.

Diagnostics

ECG

First ECG from 02.07.2025

Follow-up ECG from 02.07.2025

Chest X-ray from 02.07.2025

Laboratory tests from 02.07.2025

Echocardiography

• Left ventricle normal in size.
• Left ventricular systolic function mildly reduced, LVEF approx. 45–50%.
• Hypokinesia of the inferior and inferobasal left ventricular wall, consistent with an acute inferior myocardial infarction.
• No relevant right ventricular dilation; right ventricular function preserved.
• No hemodynamically relevant valvular lesions.
• No pericardial effusion.
• No intracardiac thrombi.

Assessment

Mildly reduced left ventricular systolic function (LVEF approx. 45–50%) with regional wall motion abnormality of the inferior and inferobasal wall in the territory of the right coronary artery. No evidence of mechanical infarction complications such as ventricular septal defect, papillary muscle rupture, or pericardial effusion.

Treatment and course

Based on the clinical symptoms, markedly elevated cardiac biomarkers, and the ECG findings with ST-segment elevations in the inferior leads and initial 3rd-degree AV block, the diagnosis of an acute ST-elevation myocardial infarction (STEMI) was made immediately and the catheterization team was alerted.

The patient was promptly placed on monitoring and received two large-bore peripheral intravenous accesses. Continuous blood pressure, pulse, and oxygen saturation monitoring were instituted and defibrillator monitoring was applied.

Initially the following medications were administered (02.07.2025):

• Acetylsalicylic acid (ASA) 500 mg i.v. as loading dose
• Ticagrelor 180 mg p.o. as loading dose
• Unfractionated heparin 5,000 IU i.v.
• Morphine 3 mg i.v. for analgesia
• Ondansetron 4 mg i.v. for nausea
• Oxygen via nasal cannula at 2 l/min, as initial oxygen saturation was 93% on room air.
• Defibrillation readiness

Nitroglycerin was withheld because of pronounced bradycardia, the 3rd-degree AV block, and the suspicion of an inferior myocardial infarction with possible right ventricular involvement.

Cardiac catheterization

Coronary angiography from 02.07.2025

After guideline-appropriate acute therapy, emergency coronary angiography was performed via the right radial artery.

Coronary angiographic findings:

Left main (LM): No hemodynamically relevant stenosis.

Left anterior descending artery (LAD): Mild atherosclerotic irregularities without stenosis requiring intervention.

Left circumflex artery (LCX): No relevant stenosis.

Right coronary artery (RCA): High-grade diffuse stenosis in the mid segment (Mid RCA) as the infarct-related artery.

The angiographic findings correlated with the clinical picture of an acute inferoposterior ST-elevation myocardial infarction.

Primary PCI

The primary percutaneous coronary intervention (PCI) was performed immediately thereafter.

After crossing the lesion with a guidewire, balloon predilation was performed. This was followed by implantation of a drug-eluting coronary stent (DES) in the area of the high-grade diffuse stenosis of the mid right coronary artery.

The final control angiography demonstrated an excellent result with complete restoration of coronary blood flow (TIMI-III flow) without relevant residual stenosis or angiographic evidence of dissection.

The procedure was uncomplicated. After successful revascularization the chest pain resolved completely. The patient was hemodynamically stable and was subsequently transferred to the internal medicine intensive care unit for further monitoring. During the further inpatient course no relevant arrhythmias or mechanical infarction complications occurred. Follow-up ECGs showed marked regression of the ST-segment changes, and the cardiac biomarkers followed the typical infarction course with subsequent continuous decline.

Post-PCI control ECG

Course of cardiac biomarkers

Discharge and recommendations

The patient was discharged on 06.07.2025 in a markedly improved general condition and stable cardiovascular status for outpatient follow-up after an uncomplicated inpatient course.

At the time of discharge the patient was asymptomatic. Chest pain had resolved. Vital signs were stable and no relevant cardiac arrhythmia was noted. The puncture site at the right radial artery was unremarkable and without bleeding.

Medication

Follow-up

Presentation to the primary care physician within one week after discharge.

Outpatient cardiology follow-up after 4–6 weeks.

Participation in an outpatient or inpatient cardiac rehabilitation program.

Regular monitoring of blood pressure, heart rate, and blood glucose.

Regular monitoring of lipid profile as well as liver and renal function tests.

Echocardiographic follow-up after approximately three months.

In case of recurrent chest pain, dyspnea, or syncope, immediate emergency re-presentation.

Patient education and counseling

The patient was extensively informed about the disease of acute myocardial infarction and the underlying coronary artery disease.

In particular, it was explained:

The prescribed medications must be taken regularly and consistently.

The dual antiplatelet therapy with ASA and Ticagrelor must not be discontinued independently, as this would otherwise substantially increase the risk of stent thrombosis.

Consistent management of cardiovascular risk factors is required.

A low-fat Mediterranean diet, regular physical activity according to tolerance, and weight reduction were recommended.

Strict smoking cessation was strongly advised. Alcohol consumption should be minimized.

The patient was informed about warning symptoms such as recurrent chest pain, shortness of breath, syncope, or palpitations and instructed to call emergency services immediately in such cases.

Prognosis

After successful primary percutaneous coronary intervention with complete revascularization of the right coronary artery, the short-term prognosis is generally favorable.

Long-term prognosis depends largely on consistent adherence to the recommended pharmacological secondary prevention, control of cardiovascular risk factors, and participation in cardiac rehabilitation.

With good therapy adherence and consistent lifestyle modification, a favorable further cardiac development can be expected.