Question

It is midmorning on the cardiac unit where you work, and you are getting a new patient. G.P. is a 60-yr old retired businessman, who is married and has 3 grown children. As you take his health history, he tells you that he began feeling changes in his heart rhythm about 10 days ago. He has hypertension (HTN) and a 5-yr history of angina pectoris. During the past week, he has had frequent episodes of mid-chest discomfort. The chest pain has awakened him from sleep but does not go away when he takes nitroglycerin (NTG), which he has been taking sublingually (SL) about 8-10 times over the past week. During the week, he has also experienced increased fatigue. He states, "I just feel crappy all the time". A cardiac catheterization procedure several years ago revealed 50% stenosis of the right coronary artery (RCA) and 50% stenosis of the left anterior descending coronary artery. He takes amlodipine, metoprolol, atorvastatin (Lipitor), and baby aspirin 81mg/day.

Answer 1

The patient has history of cardiac dysrhythmias for the past 10 years and also undergone cardiac catheterization due to coronary artery stenosis which is an evidence of atherosclerosis. He also has history of angina pectoris, hypertension . These factors can lead to severe cardiac problems which can be associated with the present condition of the patient.

Ischemic cardiac pain or angina pectoris is due to the lack of oxygen supply to the cardiac muscles due to narrowing of coronary arteries which supply them.

1. The type of angina include stable and unstable. Stable angina occurs during exertion and symptoms are relieved by taking rest or sublingual nitroglycerine. In this patient, the pain is present during resting period and the nitroglycerine administration has no significant effect in reduction of pain which is a clue for unstable angina which is a form of acute coronary syndrome. The duration and frequency of each chest pain episode to be asked because in unstable angina, the duration will be more then 10 minutes and the intensity will be more severe, prolonged, or frequent than previous each episodes. Unstable angina is an indicator of impending cardiac arrest. The type of chest pain to be asked, because the angina will be feeling of pressure, squeezing,  heaviness, tightness, burning or fullness.

2. Apart from chest pain, the ischemic cardiac pain can be radiated to the epigastrium (upper central abdomen), back, neck area, jaw, or shoulders and often inner left arm.

3. Atherosclerosis is the formation of plaque in the inner wall of the arteries due to deposition of fatty materials which leads to narrowing of the arteries and cause ischemia to the tissues where the artery is supplied. When the atheroscerosis progress, it can leads complete blockage of vital arteries in the body and can cause cardiovascular diseases which include cardiac arrest due to myocardial ischemia, stroke due to brain tissue damage, peripheral vascular disease.

4. The patient already has the risk factors like hypertension, atherosclerosis, hyperlipidemia (he is taking medications for high cholesterol ). The other risk factors include diabetes, lack of exercise and obesity, use of tobacco and alcohol, stress, and family history of heart disease and death. Thus more information regarding life style habits like how regular he do exercise, what are the dietary pattern, use of tobacco and alcohol to be asked in detail to plan and teach about life style modifications.