Question

A 79-year-old male came to the emergency department of a local hospital complaining of weakness and left arm pain. He had had an episode of profound weakness, chest pain, and left arm pain the day before admission after his daily walk. He had a history of non-insulin dependant diabetes and unstable angina.

Cardiac enzymes

	11:30 am 9/10/2001	10 pm 9/10/2001
Total CK (30-200 U/L)	100	92
CK-MB	4	3
Total LD (80-180 U/L)	155	164
Troponin T (0-0.1 mg/L)	0.2	0.1

1. What would the diagnosis be for this patient?
2. What is the cause of this condition?
3. This patient required cardiac catheritization. The patient refused this procedure but his wife said that her husband is senile and unable to decide on these things and signed his consent forms to have the procedure done. Discuss the rules and ethics of informed consent relating this to patient competence (p 104 – 110) ethics book.

Answer 1

The patient had an episode of weakness, chest pain and left arm pain. He had history of non-insulin dependent diabetes and unstable angina. Angina most commonly occurs over the age of 55 years and non-insulin dependent type II diabetes. Type II diabetes generally occurs to those who have lack of physical excercise, high fat distribution, obesity and old age. Increase in the body fat increases the plaques formation in the coronary arteries and these plaques blocking the passage of blood to the myocardium. This results into insufficient suppy of the oxygen to the cells and this leads to attack of unstable angina.

The blood tests for CK-MB and troponin is not in the normal range. As CK-MB (creatine kinase myocardial band) low level indicates the patient is suffering from chest pain and high level of troponin indicating the damage of myocardium and heart attack and it help to diagnose the myocardial ischemia.

This condition can be diagnosed by various diagnostic methods:

• Electrocardiogram (ECG)
• Coronary angiography
• Cardiac CT scan.
• Myocardial perfusion scintigraphy (MPS)

This condition can be caused due to several reasons:

• Age factor
• Poor diet
• Lack of exercise and inactivity
• Obesity and overweight due to fat
• Smoking
• Stress
• Cold environment
• Type II diabetes mellitus

All the above factors may induce the angina pectoris and myocardial ischemic condition. In this the coronary artery get narrow or blocked that limits the blood supply to the myocardium and leads to ischemia.

Cardiac catheterization is a procedure to diagnose the unstable angina or cariovascular problems. In this procedure, a long thin catheter is inserted in an artery or vein of the arm or neck or coronary artery, and guided it to the heart with a setup of a special X-ray machine. Through this catheter, a contrast dye is injected to the blood vessel and check the movement of the dye using X-ray, that gives the image of arteries or veins and indicates if there is any blockage or reduction in blood supply.

Cardiac catheterization is safe but as it is inserted into the blood vessels, so it may be associated with several risks, like bleeding, blood cloting, heart attack, infection, allergic reaction to dye etc. So, before performing a cardiac caterterization procedure, an informed consent from the patient or his/her family member is to be taken with the explaination of risk associated with the procedure. The consent is taken from the patient first, but in case patient is child, or unconsciuos, or in senile condition, a family member can give informed consent to do the procedure.