Cardiovascular Case Study
John is a 76-year-old man with a long history of stable angina and hypertension. He is prescribed nitroglycerin tablets as needed for chest pain and lisinopril for his hypertension. John has noticed that his chest pain is occurring with increasing frequency and less activity is required to initiate the symptoms; however, the pain subsides quickly with rest and one or two nitroglycerin tablets.
John is awakened from sleep with chest pain and shortness of breath. The pain is much more severe than his usual anginal pain and radiates to the jaw and the left arm. He experienced some nausea and became diaphoretic and pale. Upon admission to the local emergency department, he was noted to have significant ST-segment elevation on a 12-lead electrocardiogram (ECG).
Discussion Questions:
1. What diagnosis is consistent with John’s history and physical exam?
2. Please differentiate between a STEMI and Non-STEMI.
3. What are the pathophysiological findings specifying an MI?
4.What are the differences between angina, silent ischemia, and myocardial ischemia?
5.Provide a description of the three factors associated with Sudden Cardiac Death.
6.What are the possible complications post-MI might the NP be aware of when caring for John?
John is a 76-year-old man with a long history of stable angina and hypertension. He is prescribed nitroglycerin tablets as needed for chest pain and lisinopril for his hypertension. John has noticed that his chest pain is occurring with increasing frequency and less activity is required to initiate the symptoms; however, the pain subsides quickly with rest and one or two nitroglycerin tablets.
John is awakened from sleep with chest pain and shortness of breath. The pain is much more severe than his usual anginal pain and radiates to the jaw and the left arm. He experienced some nausea and became diaphoretic and pale. Upon admission to the local emergency department, he was noted to have significant ST-segment elevation on a 12-lead electrocardiogram (ECG).
Discussion Questions:
1. What diagnosis is consistent with John’s history and physical exam?
2. Please differentiate between a STEMI and Non-STEMI.
3. What are the pathophysiological findings specifying an MI?
4.What are the differences between angina, silent ischemia, and myocardial ischemia?
5.Provide a description of the three factors associated with Sudden Cardiac Death.
6.What are the possible complications post-MI might the NP be aware of when caring for John?
ANSWERS:
What diagnosis is consistent with John’s history and physical exam.
According to the presenting symptoms of John to the ED, the consistent diagnosis based
on the history and physical exam is either myocardial infarction (MI) or heart attack. Based on
the ECG changes, Mr John is likely to be experiencing STEMI, which is also referred to as ST-
elevation myocardial infarction. This condition requires an urgent intervention or lest lead to
irreversible complications or death. Mr John might be required to go to the cardiac
catheterization lab so that a balloon angioplasty can be out to reopen the blocked artery. Most
probably the blocked arteries are what is causing the symptoms manifested in Mr John.
Difference between the STEMI and Non-STEMI
The STEMI are characterized by the blockage of the coronary artery, which in turn
impedes blood to the epicardium hence causing cell death. This results in the dysfunction of the
heart, causing the ST in the ECG. The no-STEMI, on the other hand, occurs when there is a
blockage of either a thrombus and causes necrosis of the myocardium and the endocardium. In
the non-STEMI, there is depression of the ST segment and the T wave inversion (Dong et al.,
2015).
Pathophysiological findings specifying an MI
MI is caused by disrupted coronary blood. This results in the cyanosis of the heart
muscles and the anaerobic metabolism begins. Lack of adequate oxygen and accumulation of
lactic acid and hydrogen ions collect; hence, ATP production is ceased leading to the death of
cardiac cells (Anderson, & Morrow., 2017).
Difference between angina, silent ischemia, and myocardial ischemia.
CASE STUDY 3
Angina is defined as the chest pain occurring due to ischemia of the cardiac muscles.
Silent ischemia is also the inadequate supply of oxygen to the heart muscles but does not cause
chest pain, but rather they will complain of shortness of breath, and lethargy. Myocardial
infarction, on the other hand, is caused by an inadequate supply of oxygen to the myocardial
cells causing chest pain which can further extend to the arms neck and the jaws (Anderson, &
Morrow., 2017).
Description of factors which are associated with sudden cardiac death.
Formation of a thrombus partially or fully impedes the coronary artery and blood supply
to the heart muscles are disrupted causes cardiac cell death and may cause death. Arrhythmias
also can be a cause of sudden death, and lastly, cardiogenic shock is known to cause sudden
death (Ibanez et al., 2017).
Possible complications post-MI might the NP be aware of when caring for John
As John is required to be admitted in the in-patient post cardiac catheterization, it is
essential that he is regularly monitored for the post-MI complications. This because in the first
24 hours, the patient is still at risk of sudden death (Ibanez et al., 2017). John might be at risk of
deep venous thrombosis; hence, they should be given prophylaxis. He is at risk of cardiac
arrhythmias; therefore, it should be regularly monitored, and even during discharge, they should
be educated on the dysthymias and its symptoms.
CASE STUDY 4
References
Anderson, J. L., & Morrow, D. A. (2017). Acute myocardial infarction. New England Journal of
Medicine, 376(21), 2053-2064.
Dong, L., Mintz, G. S., Witzenbichler, B., Metzger, D. C., Rinaldi, M. J., Duffy, P. L., … & Xu,
K. (2015). Comparison of plaque characteristics in narrowings with ST-elevation
myocardial infarction (STEMI), non-STEMI/unstable angina pectoris and stable coronary
artery disease (from the ADAPT-DES IVUS Substudy). The American journal of
cardiology, 115(7), 860-866.
Ibanez, B., James, S., Agewall, S., Antunes, M. J., Bucciarelli-Ducci, C., Bueno, H., … &
Hindricks, G. (2017). 2017 ESC Guidelines for the management of acute myocardial
infarction in patients presenting with ST-segment elevation: The Task Force for the
management of acute myocardial infarction in patients presenting with ST-segment
elevation of the European Society of Cardiology (ESC). European heart journal, 39(2),
119-177.
