Question

F.M. is a 68-year-old white man who comes to the emergency department (ED) in the early afternoon with a 2-day history of severe chest pain. The pain started on wakening the previous day. The pain increased during the night, but his wife could not convince him to go to the hospital. He comes to the ED today because the pain is severe and no longer relieved by rest.

Subjective Data

• Describes recurring chest pain for the past 6 months that was relieved by rest; the pain is a feeling of heaviness in the chest with no radiating pain to arm or jaw or accompanying complaints of nausea or dizziness.
• Recently the chest pain has become severe and is no longer relieved by rest; is now complaining of being slightly nauseated.
• His father died of a heart attack at age 62.
• Smokes one pack of cigarettes per day for over 30 years.
• Describes his lifestyle as sedentary

Objective Data - Physical E x a m

• Blood pressure 180/96, pulse 98, respirations 20, Height 5’11”, weight 270 lbs
• Skin diaphoretic and clammy
• He appears anxious

Diagnostic Studies

• Chemistry panel is normal
• "Cardiac markers" lab results are pending
• Electrocardiogram showing changes that correlate with non–ST-segment–elevation myocardial infarction (NSTEMI)

Interprofessional Care

• Nitroglycerin was given and it relieves his chest pain

Discussion Questions

1. What are F.M.’s modifiable risk factors for coronary artery disease (CAD)? What are his nonmodifiable risk factors?

2. What is the difference between chronic stable angina pain and unstable angina, NSTEMI, and STEMI?

3. What could be a possible "trigger event" for the NSTEMI? Explain the pathophysiology of how it can cause a myocardial infarction.

4. What diagnostic studies are indicated for F.M.? Do you suspect the Troponin results will be normal, low, or elevated - and why?

Ongoing Case Study.

F. M is receiving treatment for his myocardial infarction and is progressing well, F.M tells the nurse following morning “I can’t breathe” the nurse notices that F. M is sitting in a tripod position and has a productive cough. His breath sounds are diminished with prolonged expiration, and his respirations are labored.

5. What in F.M.’s history is commonly associated with COPD?

6. Compare and Contrast Chronic Bronchitis and Emphysema.

7. What other clinical manifestations are associated with COPD??

Answer 1

1.What are F.M.’s modifiable risk factors for coronary artery disease (CAD)? What are his nonmodifiable risk factors?

answer:

The modifiable risk factors for coronary artery disease include the factors that the patient can change/modify to obtain  improvement in his/ her symptoms from the disease while nonmodifiable factors cannot be changed.

The Modifiable risk factors Mr FM has for his coronary artery disease are:

1. High BMI{37.7} and obesity conditions: MR FM weighs about 270 pounds and has High BMI {37.7} ;normal BMI<24.9 .With obesity, the risk of coronary artery disease increases

BMI is calculated using the BMI formula with the patients height as 5 feet 11 inches and weight beng 270 pounds

2.High blood pressure or hypertension:Mr FM has a recorded  blood pressure of 180 / 96mm Hg and probably is hypertensive. With hypertension,the risk of coronary artery disease increases

3.Chronic smoking: Mr FM smokes one cigarette pack per day for last 30 years.With smoking, the risk of coronary artery disease increases.

4.Physical inactivity or sedentary lifestyle with lack of exercise: Mr FM has a sedentary lifestyle with no exercise which increases his risk for coronary artery disease.

The modification of the above risk factors  is possible by salt restriction, taking blood pressure medications ,stopping smoking ,reducing weight and pursuing active lifestyle and exercise.

Hence these are the modifiable risk factors for the coronary artery disease Mr FM has.

The nonmodifiable risk factors Mr FM has for coronary artery disease are

1. age : Mr FM's age is a 68 years old and as the age increases, the risk of coronary artery increases due to atherosclerotic changes in the blood vessels.

2.Family history of heart attack :Mr Fm has a family history that his father died from heart attack at the age of 62. Presence of family history of heart attack increases the predisposition to myocardial infarction and coronary artery disease

3.Ethnicity:People from certain ethnic backgrounds have a higher predisposition and experience greater  mortality from the heart disease as compared to the others: Mr F.M. is a 68-year-old white man White(nonhispanic) have relative higher  mortality rates from the heart diseases.

As the above factors cannot be modified/changed, they are the non modifiable risk factors Mr FM has for the coronary artery disease.

2. What is the difference between chronic stable angina pain and unstable angina, NSTEMI, and STEMI?

answer:

Chronic stable angina is also effort angina and manifests as chest pain that is brought about by exertion and relieved on rest and medication.This occurs due to the stenosis of the coronary vessels wich are not able to supply blood to the heart muscle.At the times of stress, increased blood demand by the myocardium causes  the pain arising  from the inadequate coronary blood supply to the heart . Rest and nitrate group of drugs are used to treat chronic stable angina.

Unstable angina is caused with less stress or even at rest, has longer attacks of pain lasting for 10 minutes or more . It is  caused due to the thrombosis of the coronary vessel causing partial block and less blood supply to the myocardium and can predispose/progress to myocardial infarction if untreated immediately.

The differences between the chronic stable angina pain and unstable angina are tabulated below

NO:	chronic stable angina pain	unstable angina,
1.	The pain is brought about by exertion and stress and relieves on rest . The pain is less severe and lasts for 2 to 5 minutes	The pain occur suddenly without stress and present even at rest The pain is more severe and last for about 10 minutes
2.	The onset of pain is predictable and brought about by stressful conditions either emotional or physical stresses and responses to rest	The onset of pain is unpredictable often spontaneous, is not related to stressful conditions and can occur even during rest
3.	The pain occurs due to poor myocardial blood supply due to the stenosis in the coronary blood vessels supplying the heart	The pain occurs due to poor myocardial blood supply because of thrombosis superimposed on the coronary vessel wall plaquel with/without  vessel spasm.
4.	The pain is treated by nitroglycerin and rest and less often progresses to myocardial infarction.	The pain needs to be treated on emergent basis as there is a risk of progression to myocardial infarction without urgent medical therapy/intervention.

The difference between (chronic stable angina and unstable angina)and (NSTEMI, and STEMI) myocardial infarction

Explanation:The difference between (chronic stable angina and unstable angina)and (NSTEMI, and STEMI)is that in the  presence of myocardial infarction,there is myocardial necrosis with elevation of myocardial enzymes and ECG changes seen,both in [NSTEMI,and STEMI ]which are absent in chronic stable angina pain and unstable angina,

NSTEMI, and STEMI differ in the pathology ,progression,and the presence or absence of STsegment elevation on the ECG

The differences between the NSTEMI, and STEMI are tabulated below

no:	NSTEMI Non ST segment elevation myocardial infarction	STEMI ST segment  elevation myocardial infarction
1	Partial luminal obstruction with platelet-rich thrombus	Complete luminal occlusion with organised atherosclerotic thrombus
2	Partial block in the myocardial blood supply causing myocardial necrosis but of a lesser degree and involving only the subendocardial layer of myocardium reduced flow	Total block in the myocardial supply leading to myocardial necrosis and causing full-thickness transmural myocardial damage no flow
3	No ST segment elevation or ST segment depression on ECG	ST segment elevation on ECG
4	Less severe myocardial infarction, Treatment with medical therapy/early invasive(PCI) strategy	Very severe myocardial infarction Treatment with medical therapy/lytic therapy/ reperfusion therapy