Case 9-Coronary

Heart Disease
Mohammad Ali Ahmad

Case Summery
Ms. Yang is a 50-year-old female who experienced palpitations, shortness of breath,
and diaphoresis while exercising on a treadmill. She gives a vague history of chest
discomfort. Past medical history is significant for hypothyroidism and
gastroesophageal reflux disease. There are multiple stressors in her life. Her physical
exam is unremarkable except she appears anxious.
While evaluating these symptoms, the case reviews the classic and atypical signs of
ischemic heart pain, and contrasts the differences in presentation and outcome of
cardiac events in men vs. women. Students consider Ms. Yangs cardiac risk factors,
including family history of premature CHD, elevated cholesterol and low-density
lipoprotein (LDL), obesity, and sedentary lifestyle. Her 10-year risk of cardiac event
is calculated at low intermediate. Electrocardiogram results are normal, and several
other laboratory tests rule out other etiologies of Ms. Yangs palpitations considered
on the differential. Ms. Yang returns one week later to discuss results of her
echocardiogram, which ruled out structural abnormalities and exercise stress test,
which showed no abnormalities. She is educated about modifying her cardiac risk
factors, given tips on exercise and nutrition, and counseled regarding stress relief.

Pathophysiology
Arteriosclerosis: when part of the smooth, elastic lining
inside a coronary artery develops atherosclerosis.
Arterial lining hardens becomes stiffer, and due to
stresses on the walls, they begin to form plaques. Which
eventually lead to occlusion in the muscular layer of the
blood.
Processes occur over time, usually in the elderly, or
people who are not very compliant in maintaining a
healthy lifestyle.

Risk Factors
Lifestyle

Poor diet
Little exercise
Obesity
Smoking
Excessive Alcohol.
High Stress Level

Conditional Factors
High blood pressure
Diabetes,
High blood cholesterol

Angina
Angina Chest pain or discomfort, primarily due to lack of oxygenated blood
supply to certain areas of the heart. Feels like pressure or tightness in chest. Also
may radiate to shoulders, arms, neck, and may feel like indigestion. Angina may
be categorized as;
Stable: Which may be induced by an increase in physical activity or stressors.
Pain will go away after the inducing activity is ceased.
Unstable: Occurrence of symptoms not associated with exertions or stress, just
random and pattern less. Very dangerous and requires immediate treatment.
Common predisposition to a heart attack.
Variant (Prinzmentals): Rare and due to a coronary artery spasm, it usually
occurs at rest and can be severely painful. May occur from midnight into early
ours of the morning. Often present in females, with a complaints of migraines.
Pharmacotherapy is indicated in this form and may alleviate
symptoms/complications.

Myocardial Infarction
Non-ST-elevated and ST-elevated MI. The most common causing event
is the complication involving an atherosclerotic plaque in a coronary
artery,
Usually this complication triggers the clotting cascade, eventually
resulting in total occlusion of the artery,
Typically caused by the process of atherosclerosis typically over a long
period of time. Eventually leads to narrowing as a result of decades of
advancing atherosclerosis.
Plaques can become unstable, rupture, and additionally promote the
formation of a blood clot that occludes the artery; this can occur in
minutes. When a severe enough plaque rupture occurs in the coronary
arteries, it leads to MI, reduced blood supply ischemia eventual
necrosis(coagulative type)

Presentation and
Findings
Provocation / palliation: Other factors that may provoke angina include cold,
emotional stress, meals, or sexual intercourse.
Quality: Anginal pain is often described as squeezing, tightness, or pressure
"like an elephant sitting on my chest" although descriptions can vary widely.
Region / radiation: Anginal pain may radiate to the neck, throat, lower jaw,
teeth, upper extremity, or shoulder. A wide extension of chest pain radiation
increases the probability that it is due to myocardial infarction and radiation
to both arms is another strong predictor of acute myocardial infarction.
Associated symptoms: Anginal pain is often associated with sweating,
shortness of breath, and nausea.
Angina in women is more often to be reported with atypical symptoms.

Other Symptoms

Fatigue
Dyspnea
Neck and jaw pain
Palpitations
Cough
Nausea and vomiting
Indigestion
Back pain
Dizziness
Numbness

Women are less aggressively treated than men and have worse outcomes. The fact that women are
usually older at presentation than men and that women tend to wait longer before seeking treatment
may be part of the reason.
Women are also less likely to participate in cardiac rehabilitation. Diagnosing CHD earlier in women
are critical, because initial cardiac events in women can be fatal at a higher rate.

Diagnosis
1st Step- EKG
If STEMI present- Cath Lab/PCI (MI)
If No STEMI present- Cardiac enzyme tests(MYO, TROP, CKMB)

2nd Step
Echocardiography
Exercise Stress Test
Chemically Induced Stress Test (Dobutamine, Adenosine)
Coronary Steal Syndrome (HY Topic)

Other:
CXR-PE
CBC

Management and
Treatment
Initial- Morphine, Oxygen, Nitrates, and Aspirin.
Helps deal with patients who present acutely with symptoms of disease.

Long term management

Medications

Statins- Lowering Cholesterol

Nitroglycerin
ACE Inhibitors for Hypertension
CCBs
Beta Blockers

Coronary interventions: Angioplasty and coronary stenting

Coronary artery bypass grafting (CABG)

Prevention
Lifestyle modification
Proper Exercise
Healthy Diet
Maintain Low Stress Levels

Medical Compliance
Consistent with medications
Consistent with follow up with primary care physicians.

 WebMD. Family Life Cycle.

http://children.webmd.com/tc/family-life-cycle-topicoverview. Accessed June 2014
NIH. Coronary Heart disease.
http://www.nhlbi.nih.gov/health/health-topics/topics/cad.
Accessed June 2014

Sources