Question

Case Study

Michael O’Malley, age 49, lives in Staten Island, New York, with his wife, Sharon. He has been a New York City police office for 25 years. The O’Malleys have two sons, 20 and 16 years of age, and a daughter, 18 years of age. Mr. O’Malley has always taken pride in the fact that he is athletic, working out 3 days a week at the gym and playing softball in the police league. Overall, Mr. O’Malley is physically fit. However, despite his exercise routine, he continues to smoke two packs of cigarettes a day and drinks several beers on the weekends when he is off duty. He weighs 220 pounds, is 72 inches tall, and has a BMI of 29.8. Mr. O’Malley thrives while working the midnight shift; in fact, he prefers it. For many years while his children were small, working the night shift made it possible for him to attend school plays, baseball games, and other activities in which his children were involved. He adapted to working this shift, and even now, when his children are nearly grown, he continues to work the midnight shift. He typically relies on fast food for lunch during his work hours.

His wife, a nurse at a hospital near their home, works on the orthopedic unit. She enjoys her work and often works extra shifts to help defray the costs of college for their oldest son. Mr. O’Malley also frequently works overtime, leaving very little time for the two of them as a couple. As an officer with the NYPD, Mr. O’Malley was an emergency responder to the World Trade Center on September 11, 2001. He quickly sprinted up several floors of the north tower before being called to evacuate because the south tower had collapsed. He developed a chronic cough from dust exposure during the collapse, but over the course of several years, the cough dissipated. Happy to be alive when many of his fellow officers had perished, he did not complain about his cough and never sought medical treatment.

Mr. O’Malley is called to the scene of a domestic dispute. On arrival at the scene, he notices that the wife had several fresh bruises to her face and what appear to be fingerprints around her neck.She states that her husband has just left but said he would be back.Out of the corner of his eye, Mr. O’Malley notices an adult male running from the scene, and he gives chase. He runs after the subject for several blocks, finally catching up to him in a dead-end alley. Although trapped, the man fights with Mr. O’Malley, who has called for backup. After several minutes of intense wrestling, Mr. O’Malley finally succeeds in restraining the subject just as backup arrives.

About 30 minutes later, while filling out paperwork, Mr. O’Malley begins to feel a fullness in his chest, followed by pressure and tightness. He gets dizzy, stands up, and falls to the ground. Another officer present in the office feels for a pulse, but there is none. CPR is started, and when the paramedics arrive, Mr. O’Malley is defibrillated, and sinus rhythm is restored. He is taken to the emergency department and then the cardiac catheterization lab. A stent is placed in his left anterior descending artery. A pulmonary artery catheter is placed, after which the cardiac output is 3.5 and the cardiac index is 1.5. An intra-aortic balloon pump is placed, and milrinone, a phosphodiesterase 3 inhibitor used to treat HF, is started.

Over the course of the next several days, Mr. O’Malley’s condition stabilizes. The balloon pump is weaned and removed. An echocardiogram reveals an EF of 25%, and lisinopril, which is an ACE inhibitor, and carvedilol, which is a beta blocker, are started. Mr. O’Malley is eventually weaned off the milrinone. His EF remains low, less than 30%. An implantable cardioverter-defibrillator is placed for primary prevention of sudden cardiac death. Mr. O’Malley is discharged home after 7 days.

Mr. O’Malley elects to retire on medical disability from his job, which has been his identity for many years. At first, many of his fellow officers come by frequently to visit, but after a few months, the visits become few and far between. Mr. O’Malley stops smoking and no longer drinks alcohol on weekends. He attends a cardiac rehabilitation program for 3 months and then begins a self-directed exercise program. He learns his medications and monitors his weight, blood pressure, and pulse rate. Mrs. O’Malley continues to work full time and continues to pick up extra shifts, since Mr. O’Malley’s retirement and disability benefits do not cover the loss of his salary. Mr. O’Malley soon begins to experience depression and isolation, and after not smoking for several months, he begins smoking again. He gradually stops exercising and begins to gain weight.

A year later, Mr. O’Malley notices that his pants are getting tighter and tighter and his shoes no longer fit as well as they did. He complains to his wife that he has no energy and wonders whether he is coming down with a cold or the flu. Then he begins to wake up in the middle of the night gasping for breath. He develops lower extremity edema and progressively more fatigue. He goes to see his cardiologist, who performs an echocardiogram.

Mr. O’Malley’s EF is now 15%. Mr. O’Malley is admitted to the hospital for diuresis and medication titration. A pulmonary artery catheter is inserted. His pulmonary artery pressures are elevated, and his CO is decreased. He is again placed on milrinone, and aggressive diuresis is begun.

Mrs. O’Malley is worried. She requests family medical leave from her employer and calls their oldest son home from college. She spends a lot of time at the hospital and feels a sense of impending doom about the future, with good reason. The reports from Mr. O’Malley’s doctors are not good, and every day seems to bring another obstacle to be overcome. Mr. O’Malley suffers some kidney failure following diuresis. His milrinone is increased, and his renal function stabilizes. Once his fluid status has improved, attempts to wean the balloon pump are unsuccessful. The injury to his lungs suffered during the September 11 attacks is now apparent, and a pulmonary workup is performed. Ultimately, it is decided that he requires placement of a left ventricular assist device (LVAD).

The LVAD surgery is successful, and Mr. O’Malley recuperates quickly. Still unable to work, he begins to cook and help more with the housework. He volunteers at the local library, reading to preschool-age children. He suffers a few complications related to the LVAD, including a driveline infection. He has regular visits with the LVAD team, and things are going well for a change. After 6 months, his care team decides that Mr. O’Malley is now a candidate for heart transplantation. His pulmonary function has improved, and he has stopped smoking. He is listed for a donor heart and receives his transplant 2 months later.

Answer the following questions in 2-3 sentences.

1. What was the initial cardiac injury that Mr. O’Malley suffered?

2. What are three habits that Mr. O’Malley has that can negatively affect his heart?

3. What type of HF is Mr. O’Malley experiencing, and what can cause it?

4. What are some of the factors that may have caused Mr. O’Malley to experience systolic HF?

5. Mr. O’Malley was started on a medication regimen and had what surgical intervention to prevent sudden cardiac death?

6. What are a few self-care activities that Mr. O’Malley did to decrease exacerbations?

7. What is one complication that Mr. O’Malley faced after receiving the LVAD?

8. What two events occurred that allowed Mr. O’Malley to be placed on a donor list for a heart transplant?

Answer 1

1. What was the initial cardiac injury that Mr. O’Malley suffered?

answer:

The initial cardiac injury that Mr O'Malley suffered was anterior wall myocardial infarction with cardiac arrest/cardiac standstill due to left anterior descending artery block caused by coronary artery disease. This. can be inferred from the fact that Mr O' Malley had episode of fullness in his chest, followed by pressure and tightness. further followed by collapse and unconsciousness and had emergency stenting done for the left anterior descending artery following the episode.

The cardiac injury suffered due to the myocardial infarction was myocardial necrosis eventually causing myocardial dysfunction and heart failure

2. What are three habits that Mr. O’Malley has that can negatively affect his heart?

answer:

The three habits that Mr O'Malley has that can negatively affect his heart are listed below:

1)The habit of smoking: Smoking is known to cause accelerated atherosclerosis and increase the risk of coronary heart disease.

2) The habit of eating fast food for lunch during workhours: Fast foods are rich in trans fats and can cause obesity and damage the blood vessels by  atherosclerotic plaque formation in the blood vessels and aggravate coronary artery disease.

3The habit of drinking several beers over the weekend : The unregulated drinking of beer which contains about 5% alcohol can cause alcohol related coronary vessel disease and can also lead to obesity.

3.What type of HF is Mr. O’Malley experiencing, and what can cause it?

answer: Mr O'Malley is experiencing left sided systolic congestive heart failure.

The factors that can cause it include myocardial infarction due to coronary artery disease causing myocardial necrosis and decreased myocardial contractility with poor pumping of the heart and eventually heart failure as in Mr O'Malley's case.

The most common causation for the left sided systolic congestive heart failure is coronary artery disease.

The other causative factors that can cause such kind of heart failure include cardiomyopathy, congenital heart disease ,rheumatic heart disease, viral myocarditis and valvular heart disease.

4.What are some of the factors that may have caused Mr. O’Malley to experience systolic HF?

answer:

The coronary artery disease causing myocardial damge and necrosis following myocardial infarction due to left anterior descending artery block are some of the factors that may have caused Mr. O’Malley to experience systolic HF. VentricularSeptal damage, papillary muscle necrosis, left ventricular aneurysm are some of the the consequences post myocardial infarction that can predispose to systolic heart failure.

The ischemic damage to the myocardium post myocardial infarction and poor left ventricular functioning lead to systolic heart failure.

The systolic failure was further aggravated by the lifestyle risk factors for coronary artery disease that Mr O'Malley like smoking,poor eating habits, obesity and lack of a structured physical activity and also the possibe interstitial lung disease due to lung damage sustained as a result of 9/11 rescue event debris inhalation.

5. Mr. O’Malley was started on a medication regimen and had what surgical intervention to prevent sudden cardiac death?

answer:

An implantable cardioverter-defibrillator [ implantation-surgical intervention] was had by Mr O'Malley for prevention of sudden cardiac death.Mr O’Malley had experienced an episode of cardiac arrest post myocardial infarction due to coronary artery disease. His life had been saved by emergency CPR and defibrillation .He was at high risk of experiencing such episodes in future too , following the myocardial infarction. An implantable cardioverter defibrillator can prevent or correct arrhythmias and also restore the heart beat in case the heart suddenly stops beating. Hence the surgical intervention of implanting a cardioverter-defibrillator was done for Mr O’Malley.

6. What are a few self-care activities that Mr. O’Malley did to decrease exacerbations?

answer: The few self-care activities that Mr. O’Malley did to decrease exacerbations are:

1. He retired on medical disability grounds from his job

2.Mr. O’Malley stopped smoking.

3.He stopped drinking alcohol on weekends.

4.He attended a cardiac rehabilitation program for 3 months and then began a self-directed exercise program.

5.He learnt his medications and monitored his weight, blood pressure, and pulse rate

7. What is one complication that Mr. O’Malley faced after receiving the LVAD?

answer: Mr. O’Malley suffered quite a few complications related to the LVAD, the significant one being a driveline infection.

Drive line infection is defined as the soft tissue infection around the exit of the driveline of the LVAD device. This is caused by the bacterial infection around the prosthetic materials,The prosthetic materials creates a conducive  environment for the bacteria to thrive and multipy.

8. What two events occurred that allowed Mr. O’Malley to be placed on a donor list for a heart transplant?answer:

The  two events occurred that allowed Mr. O’Malley to be placed on a donor list for a heart transplant are

1.His pulmonary function had improved, and

2.He had stopped smoking.

Stoppage of smoking and improvement in the pulmonary function tests are the prerequisites for the success in heart transplantation.