5 mins post vaccination pt c/o chest pain.  He describes it as sharp, constant, radiating to his left chest and back as well as his left shoulder.  He states that it is unremitting, not improved with several of his own nitroglycerin.   911 was called @19:35 Pt then had 3 episodes of vomiting.  When EMS arrived, pt was given NTG and ASA and transferred to the ED.  Pt reports that morphine helps with the pain.  Pt was admitted for further care.  Symptoms due to ongoing underlying conditions.  Per Discharge Note 12/11 Hospital Problems:  54 y.o. male with ho DM2, HLD, HTN, HFrEF EF 45% and diastolic dysfx 11/2021 at RMC, last nuclear stress test negative 6/2021, CAD s/p DES x 5 (RCA s/p PTCA and thrombectomy of prox RCA stent in 2011 at SCVMC stents in the past with chronic angina who presents with chest pain    # Acute on Chronic angina with CAD, challenging case, with innumerable visits for chest pain, negative troponins, refused repeat stress last month; had refused cath in the past as his most recent stent 2019 didn't help his chronic chest pain. Trop flat at 24, EKG non ischemic. LDL 68, HbA1c 8.7. - Cont Aspirin, Plavix, Coreg. - resumed imdur 30 mg daily and ranexa 500mg BID  - Cardiology consulted, TTE 12/9: Normal LV systolic function, mild diastolic dysfunction Grade I, severely dilated LA, , - Cardiology recommended stress test but patient refused to have stress test, hence cardiology performed cardiac cath on 12/10 that showed Chronic total occlusion of proximal-Mid RCA with good collaterals, otherwise no obstructive CAD, patent LAD stent -Cardiology recommended: S/p cardiac catheterization               -Total occlusion of RCA (chronic) with multiple collaterals               -Strict bedrest for 3 hours               -No strenuous activity or heavy lifting (>20 lbs) for 1 week -Continue renexa 500mg BID  -Continue imdur 30mg daily -Continue PTA aspirin 81mg, plavix 75mg, coreg 25mg  -Follow-up in outpatient cardiology clinic with cardiology - pt continued to request morphine solution or norco pills for chest pain, despite educating him that this is not the standard of care for angina and that he needs to take anginal meds per cardiology -No opioids were given at discharge     # chronic systolic and diastolic HF, no acute HF symptoms now   # HTN - resumed lisinopril, and coreg    # DM2 with neuropathy - on gabapentin -  LISS and prandial insulin   # Mood disorder, - taking wellbutrin and duloxetine   Consults Obtained: Cardiology 12/10 Patient is a 54 y/o M with extensive cardiac history (with multiple reported PCIs in the past) along with multiple cardiac RF: DM2, HTN, HLD) and h/o HFrEF (EF 45% and diastolic dysfx 11/2021 at RMC) who presents with acute on chronic angina. He has been seen and RMC 2-3 times in the past month for the same. Low concern for ACS at this time given very low troponin elevation which is stable and no new acute ischemic EKG changes. Suspect his worsening anginal symptoms are in the setting of not taking his appropriate home meds of ranexa and imdur - though his symptoms persist depsite medical managment. Given his symptoms, HEART score of 5 and known CAD/multiple cardiac RF, and relatively unremarkable TTE - he warranted inpatient stress test, though he adamantly refused (stating he almost died), therefore we proceeded with LHC.    LHC showed proximal-mid chronic total occlusion at proximal stent edge (multiple stents noted), grade 1 right to right bridging collaterals and grade 2 left to right collaterals. Per cath lab: Patient noted to have vasovagal reaction after access (no sedation given, so not a reaction to sedation). This responded well to normal saline IV bolus, IV phenylephrine, and IV atropine. He reportedly denies any further chest pain s/p catheterization. At this time, plan will be continue aggressive medical management of CAD RF and continue with anti-anginal therapy.    Recommendations: -S/p cardiac catheterization today:               -Total occlusion of RCA (chronic) with multiple collaterals               -Strict bedrest for 3 hours               -No strenuous activity or heavy lifting (>20 lbs) for 1 week -Continue renexa 500mg BID  -Continue imdur 30mg daily -Continue PTA aspirin 81mg, plavix 75mg, coreg 25mg  -Follow-up in outpatient cardiology clinic with cardiology