text:  Aspirin 325 mg. PO q.d. Lipitor 80 mg. PO q.d. Toprol XL 50 mg. PO q.d. Lasix 80 mg. q.a.m. and 40 mg. q.p.m. Potassium chloride 20 mEq. PO b.i.d. Citracal 1 packet q.d. Imdur 60 mg. PO q.d. Vitamin E 400 international units q.d. Prilosec 20 mg. PO q.d. HISTORY OF PRESENT ILLNESS Breunlinke is a 70-year-old patient of Dr. Brendniungand Asilbekote in California . She is referred for progressive angina . She had rheumatoid fever as a child and a heart murmur noted but no further testing . She has used antibiotic prophylaxis since 1980 . In 1980 she had quadruple coronary artery bypass graft surgery by Dr. Elks at Feargunwake Otacaa Community Hospital and did well until 1988 when she had exertional angina and a positive stress test and found that three or four grafts were occluded . In October   1989   Dr. No re-did her bypass operation . She had a left internal mammary artery graft to the left anterior descending   saphenous vein graft to the obtuse marginal 1 and a saphenous vein graft to the obtuse marginal 2 . In 1993 she had a DDD pacemaker for complete heart block . She had exertional angina at that time . In November   1997 she had a small myocardial infarction as was transferred to Ona Hospital where a cardiac catheterization showed a tight left internal mammary artery to left anterior descending stenosis   high grade saphenous vein graft to obtuse marginal 1 stenosis and patent obtuse marginal 2 graft . She had normal left ventricular function with apical tip akinesis . Since that time she has continued to have exertional left chest burning   radiating to the left neck and arm   relieved by nitroglycerin . She was turned down for re-do surgery at that time and did not have a percutaneous transluminal coronary angioplasty . Because these symptoms have been increasing   particularly at cardiac rehabilitation   she was referred here . In May   1998 she had an exercise tolerance test in which her heart rate went to 112 and her blood pressure fell to 95 systolic . She had diffuse ischemic ST segment changes and increased lung uptake and a reversible anterior and lateral defect . She has had no syncope . Her cardiac risk factors are hypertension and elevated cholesterol . She has a very strong family history of coronary artery disease with a mother   sister and brother dying of myocardial infarction . She is a remote cigarette smoker . She also has a history of lactose intolerance   peptic ulcer disease   with a remote gastrointestinal bleed and multiple ectopic pregnancies and mid term miscarriages . She has had a total abdominal hysterectomy .