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Answers on p 416.
A 53 year old woman presented with pulmonary oedema after an inferior myocardial infarction three months earlier. Blood pressure on admission was 210/120 mm Hg. Initial treatment included diuretics, nitrates, and oxygen and her symptoms settled. Echocardiography before discharge showed mild impairment of left ventricular contraction. Coronary angiography performed several months later showed an occluded right coronary artery, with a 50% stenosis of the left anterior descending vessel. Overall left ventricular function was good (ejection fraction of 58%) with some regional inferior hypokinesia. Over the next two years, the patient was admitted on numerous occasions with hypertensive pulmonary oedema and was treated medically. Between admissions she remained symptom free although blood pressure control was difficult.
- What is the most likely cause of this patient's recurrent pulmonary oedema?
- What investigations should be performed next?
- What treatment options are available to this patient?