Question

Mr. Bassen, a 55-year-old male has been experiencing a rapid, strong, and irregular heartbeat over the last twelve hours. Over the last four hours, he has been experiencing chest pain that has become even more severe over the past hour prompting him to call 911. He describes the pain as localized pressure behind his sternum and he is having trouble breathing and is experiencing nausea. His medical history includes untreated high blood pressure and daily tobacco and alcohol use over the last 30 years. His father experienced high blood pressure and a stroke at age 60. The paramedics take his vital signs that show a blood pressure of 160/100 mm Hg, a heart rate of 96 beats per minute, and a respiratory rate of 22 per minute. Nothing else significant is noted on his exam.

1. What are your initial observations of the patient in this case?
2. What do you think the diagnosis may be? What are the associated cellular and physiological mechanisms that may be occurring?
3. What are the survival rates associated with this diagnosis?
4. What may be the treatment options for this patient?
5. Create a flow chart identifying the major risk factors for heart disease, their mechanisms, physiological outcomes, and lifestyle/medical changes that can be made to reverse them.

Answer 1

Question 1 the initial observation include the demographic details, history collection and physical examination.

Retrosternal chest pain since 4 hours which increased over the past one hour.

Palpitations.

Dyspnea.

Nausea.

Medical history reveals known case of diabetes for the past 30 years and daily tobacco and alcohol for the past 30 years.

Positive familial history suggestive of hypertension, stroke.

Physical examination reveals BP of 160 /100 mmhg, PR of 96 and RS of 22 per minute.

Question 2. The probable diagnosis can be a acute coronary syndrome. The three conditions include.

ST elevation myocardial infarction.

Non STelevation myocardial infarction.

Unstable angina.

Physiological mechanism.

Elevated demand can produce ACS in the presence of a high-grade fixed coronary obstruction, due to increased myocardial oxygen and nutrition requirements, such as those resulting from exertion, emotional stress, or physiologic stress (eg, from dehydration, blood loss, hypotension, infection, thyrotoxicosis, or surgery).

The major trigger for coronary thrombosis is considered to be plaque rupture caused by the dissolution of the fibrous cap, the dissolution itself being the result of the release of metalloproteinases (collagenases) from activated inflammatory cells. This event is followed by platelet activation and aggregation, activation of the coagulation pathway, and vasoconstriction. This process culminates in coronary intraluminal thrombosis and variable degrees of vascular occlusion.

Question 3.the recovery mainly depends upon the window period, the type of MI, the extend of myocardial damage, and presence of comorbid conditions.

Six-month mortality rates in the Global Registry of Acute Coronary Events (GRACE) were 13% for patients with NSTEMI ACS and 8% for those with unstable angina.

In a study that assessed the impact of prehospital time on STEMI outcome, Chughatai et al suggest that "total time to treatment" should be used as a core measure instead of "door-to-balloon time."This is because on-scene time was the biggest fraction of "pre-hospital time." The study compared groups with total time to treatment of more than 120 minutes compared with 120 minutes or less and found mortalities were 4 compared with 0 and transfers to a tertiary care facility were 3 compared with 1, respectively.

Question 4.management.

Initial therapy focuses on the following:

Stabilizing the patient’s condition

Relieving ischemic pain

Providing antithrombotic therapy.

Pharmacologic anti-ischemic therapy includes the following:

Nitrates (for symptomatic relief)

Beta blockers (eg, metoprolol): These are indicated in all patients unless contraindicated.

Pharmacologic antithrombotic therapy includes the following:

Aspirin

Clopidogrel

Prasugrel

Ticagrelor

Glycoprotein IIb/IIIa receptor antagonists (abciximab, eptifibatide, tirofiban).

Pharmacologic anticoagulant therapy includes the following:

Unfractionated heparin (UFH)

Low-molecular-weight heparin (LMWH; dalteparin, nadroparin, enoxaparin)

Factor Xa inhibitors (rivaroxaban, fondaparinux).

Additional therapeutic measures that may be indicated include the following:

Thrombolysis(streptokinase, urokinase and reteplase)

Percutaneous coronary intervention.

Question 5. Risk factors

Nonmodifiable risk factors include familial history, increasing age, gender and race.

Modifiable risk factors include dyslipidemia, cigarette smoking, tobacco use, hypertension, diabetes mellitus, metabolic syndrome, obesity and physical inactivity.

Patient education.

Educate patients about the dangers of cigarette smoking, a major risk factor for coronary artery disease (CAD). The risk of recurrent coronary events decreases 50% at 1 year after smoking cessation. Provide all patients who smoke with guidance, education, and support to avoid smoking. Smoking-cessation classes should be offered to help patients avoid smoking after a myocardial infarction. Bupropion increases the likelihood of successful smoking cessation.

Diet plays an important role in the development of CAD. Therefore, prior to hospital discharge, a patient who has had a myocardial infarction should be evaluated by a dietitian. Patients should be informed about the benefits of a low-cholesterol, low-salt diet. In addition, educate patients about AHA dietary guidelines regarding a low-fat, low-cholesterol diet.

A cardiac rehabilitation program after discharge may reinforce education and enhance compliance.

The following mnemonic may useful in educating patients with CAD regarding treatments and lifestyle changes necessitated by their condition:

A = Aspirin and antianginals

B = Beta blockers and blood pressure (BP)

C = Cholesterol and cigarettes

D = Diet and diabetes

E = Exercise and education.

For patients being discharged home, emphasize the following.

Timely follow-up with primary care provider

Compliance with discharge medications, specifically aspirin and other medications used to control symptoms

Need to return to the ED for any change in frequency or severity of symptoms