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A 49-year-old woman with a history of hypertension and insulin-dependent diabetes mellitus presented to an outside medical institution with the chief complaint of retrosternal chest pressure. The chest pain occurred at rest, radiated to both arms, was associated with shortness of breath, and was relieved with sublingual nitroglycerin. The presenting ECG showed an inferior and anterolateral infarct pattern without evidence of acute ST segment changes. Acute myocardial infarction was excluded by the absence of cardiac enzyme changes (creatine kinase-MB and lactate dehydrogenase). Cardiac catheterization revealed three-vessel coronary artery disease (90% proximal right coronary artery, 70% left anterior descending, 60% proximal first obtuse marginal) with a left ventricular ejection fraction of 35%. She was referred to Hermann Hospital, Houston, for further evaluation and therapy and underwent three-vessel saphenous vein grafting to the left anterior descending, obtuse marginal, and right coronary arteries. The left internal

A 49-year-old woman with progressive peripheral edema and jugular venous distension after bypass and defibrillator placement.