THE HEART III – Chapter 19

Case Study
Michael, who is 42 years old and the president of a small and rapidly-growing business, was just
beginning his kickboxing class at the local gym when he noticed a slight tightness in his chest. As he
continued his workout, the pain became more severe and radiated to his left arm, shoulder, and jaw.
Michael thought he had pulled a shoulder muscle and headed for the showers. He decided to go back to
work for the rest of the day and see how he felt tomorrow before making plans to return to the gym.

After returning to his office, he began to sweat and mentioned to his assistant that he had an
upset stomach. This, coupled with his experience at the gym, made him think that he might be coming
down with the flu instead, but as he needed to get a few things done before going home, he asked his
assistant, Sam, to gather some files for the necessary projects and bring them to him. When Sam
returned with the files approximately 10 minutes later, he found Michael unconscious on the floor of his
office and called an ambulance.

When the paramedics arrived, they found that Michael was not breathing and had no detectable
pulse. His skin was pale, cool, and clammy. They initiated cardiopulmonary resuscitation, reestablished
breathing and a regular heartbeat, and transported Michael to the hospital. On the way, Michael regained
consciousness, and a paramedic gave him a nitroglycerin tablet to place under his tongue and then
aspirin to chew. During transport to the hospital, the paramedics recorded the following vital signs:

Heart rate = 50 beats/min and irregular

Blood pressure = 74/48 mmHg
Respiratory rate = 16 breaths/min and shallow

At the hospital, Michael was promptly placed on a cardiac monitor, blood was drawn to check for
circulating cardiac troponin I and creatinine kinase MB (CK-MB), and his electrolytes, blood pressure, and
pulse oxygen saturation was closely monitored. His blood work showed elevated levels of troponin I and
CK-MB and his pulse oximetry showed an 85% saturation. His ECG demonstrated that his ST segment
was elevated which resulted in the prognosis of STEMI. An angiography confirmed occlusion of his
circumflex artery. After meeting with his cardiologist, he was taken directly to the cardiac catheterization
lab where a drug eluting stent (DES) was placed in his circumflex artery via a procedure called
percutaneous coronary intervention.

Once Michael was stabilized, he was transported to the cardiac care unit (CCU) where he was
put on nasal oxygen and Integrilin (Eptifibatide) was administered via an intravenous drip. Later that
evening, after adequate hemostasis at the puncture site where the catheter was inserted, he was
encouraged to get up and walk with assistance.

Michael was kept in the hospital for 2 to 3 days for monitoring and treatment. He was seen by the
dietitian, his cardiologist, and a hospitalist who contacted his primary care physician (PCP) on discharge.
His primary care physician was well aware of Michael’s history: Michael was divorced and overweight,
smoked up to two packs of cigarettes per day, was under treatment for hyperlipidemia, and had a family
history of hypertension. Michael was frightened by his hospitalization and resolved to change his diet to
both lose weight and address his blood lipid/cholesterol levels and also to quit smoking.

When Michael was discharged, he was prescribed the following medications to take for at least a
year: aspirin, Plavix (Clopidogrel), a beta blocker (Metaprolol), an ACE inhibitor (Ramipril), and Lipitor
(Atorvastatin), which is the Cardiac CORE standard. He was scheduled to see his PCP in one week and
his cardiologist in 2 weeks who will consider whether cardiac rehabilitation is appropriate.

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Day 1 – Preparation:
1. What do you know about Michael’s symptoms, disorder and treatments from reading this
case and from readings or other experiences?

Symptoms:
Tightness in his chest, pain went down left arm to shoulder and jaw. He was sweating and
also had an upset stomach. A few hours later, he was found unconscious. Paramedics
found no pulse and the patient had stopped breathing. His skin was pale, cool, and clammy.
They used CPR to reestablish breathing and heartbeat. His vitals:
Heart rate: 50 beat/min and irregular Resp.: 16 b/m and shallow BP: 74/48mmHg

All of the above symptoms are evidence that Michael suffered a heart attack.

Further evidence that Michael’s heart attack resulted from a blocked artery:

 Blood work showed elevated levels of troponin I and CK-MB - 80% or more of whose
suffering an acute myocardial infarction have such elevated levels in the hours
following the heart attack. (Source: https://www.ncbi.nlm.nih.gov/pubmed/9386162)

 Pulse oximetry showed an 85% saturation - heart attack patients show this
deficiency (hypoxia) in the level of oxygen reaching the tissues (which should be at
least 96%)

 ECG demonstrated that his ST segment was elevated which resulted in the
prognosis of STEMI - A STEMI or ST-elevation myocardial infarction is caused by
a sudden complete (100 percent) blockage of a heart artery (coronary artery).
(Source: https://www.sharecare.com/health/heart-attack/what-is-the-difference-
between-stemi-and- )

 Angiography confirmed occlusion (blockage) of his circumflex artery.

Treatment:
A drug eluting stent (DES) was placed in his circumflex artery via a procedure called
percutaneous coronary intervention. He was placed on oxygen to help with his O2 levels
and Integrilin (Eptifibatide) (prevention of clotting or further damage during heart attack) was
administered via an intravenous drip. Upon release, Michael was prescribed medications to
take for at least a year: aspirin, Plavix (Clopidogrel), a beta blocker (Metaprolol), an ACE
inhibitor (Ramipril), and Lipitor (Atorvastatin). He was to follow up with his physician for
possible cardiac rehabilitation.

2. What would you like to know? What information is provided in the case that you don’t
understand? I would like to know if there were any additional blockages or partial occlusions
given that heart attacks can result from several blockages at once with several stents inserted
as treatment at the same time. I understood the information provided after researching it.

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Day 2 – Follow Up: Answer the following questions on a separate sheet. Cite all of the
resources/references you use.

1. Describe the risk factors that increased the probability that Michael would have an MI at some
point.

Risk factors would be the patient’s divorce (stress), high cholesterol (hyperlipemia),
being overweight, a family history of hypertension, and smoking 2 packs a day.

2. Explain what each of the following physical signs or symptoms and blood values measures;
where values are given, note whether each value is high, low or normal (so you’ll need to do a
little research to determine what normal values are), and what the value suggests about
Michael’s physiology. In other words, explain how/why an MI would result in each of these
signs, symptoms or blood values.

a. Elevated cardiac troponin & creatine kinase

-Troponin will become elevated and remain elevated for two weeks it may indicate an
increased risk of heart attack
-high levels for troponin. He was above the normal level which is .04
-an elevated creatine kinase level likely means that there has been injury or stress to
muscle tissue like the heart
-he had a high creatine level the normal level is from 42-192
(Source: medlineplus.gov)

b. Pulse oximetry
-measures oxygen saturation level in blood and if able to evaluate if the patient is getting
enough oxygen to blood to saturate tissues.
-his oxygen levels were very level 85% (normal is 96% or above).
(Source: https://acphospitalist.org/archives/2009/12/tech.htm )

c. Heart rate
- rate which the heart pumps in beats per minute. Too low of a heart rate could mean not
that the heart is not working correctly and not enough oxygenated blood is being
circulated to tissues.
-Michael’s heart rate taken by the paramedics is low- normal heart rate is 60-100bpm.

d. BP
-the force of the blood moving through the vessels; to high of blood pressure can be
dangerous because it’s putting too much stress on the heart or blood vessels in the brain
and it’s hard to move the blood causing strokes or heart attacks; low blood is also
dangerous as it causes dizziness and lightheadedness
-Michael's blood pressure taken by the paramedics is very low - normal range is
120/80-140/90.

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e. Respiration
-the number of breaths taken per minute (normal range for is between 8-16).
-Michael’s respiration was just within the normal range, but shallow; shallow breathing
can indicate heart failure or other medical issues showing interfere with the exchange of
gases between blood and tissue.

f. Blockage in circumflex artery – here, specifically note what area(s) of the heart would have
suffered ischemia due to the blockage
- if the artery is blocked completely it well cause a myocardial infarction. Heart muscle
will die because it’s not getting blood and it will affect the left side of the heart, also the
lateral and back side of the heart will be affected

g. Hyperlipidemia -The medical term for high blood cholesterol is lipid disorder, or
hyperlipidemia,
-Michael’s lipid count was high given his treatment history for this condition.
-A total cholesterol level of less than 200 mg/dL (5.17 mmol/L) is normal. A total
cholesterol level of 200 to 239 mg/dL (5.17 to 6.18 mmol/L) is borderline high. A total
cholesterol level greater than or equal to 240 mg/dL (6.21 mmol/L) is high.

Sources:
https://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heartattack.htm ;
https://www.mayoclinic.org/diseases-conditions/heartburn/in-depth/heartburn-gerd/art-
20046483;
https://www.heart.org/en/health-topics/heart-attack/warning-signs-of-a-heart-attack ;
https://www.hopkinsmedicine.org/healthlibrary/conditions/cardiovascular_diseases/vital_signs_b
ody_temperature_pulse_rate_respiration_rate_blood_pressure_85,p00866
https://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heartattack.htm

3. Describe/explain the purpose of each of the following treatments or drugs and briefly explain
how each works. How did each help alleviate his current symptoms or prevent future MI’s?

a. Nitroglycerine -used for during or after chest pain(angina) helps widen blood vessels so more
blood gets to heart muscle.

b. Aspirin -used to reduce fever, relieve pain and prevent blood clots. Can be used as blood
thinner. Work by blocking natural substance in body

c. Use of a drug eluting stent- coronary balloon to open blood artery.

d. Integrilin (Eptifibatide)- blood thinner. Help prevent blood clot during heart attack

e. Nasal Oxygen - used to deliver extra oxygen or increased air flow to a patient. Can be used
to help raise oxygen levels

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f. Plavix (Clopidogrel) - blood thinner. Can prevent heart attack, stroke and other heart problems

g. Beta blocker (Metaprolol) - causes blood vessels to relax, by relaxing the blood vessels, beta
blockers help lower heart rate and decrease the heart’s demand for oxygen results in
decreasing blood pressure and reduces chest pain.

h. ACE inhibitor (Ramipril) - enzyme that is used as heart medication to widen or dilate blood
vessels that increases amount of blood the heart pumps and lowers blood pressure and raises
blood flow. It prevents angiotensin II.

i. Lipitor (Atorvastatin)- treats high cholesterol and triglyceride levels. Reduces risk of heart
attack, stroke, angina and heart and blood vessel problems.

(Source: https://www.rxlist.com/ )

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