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Article Contents

Answer to part 1, answer to part 2, answer to part 3, answer to part 4, answer to part 5.

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Educational Case: A 57-year-old man with chest pain

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Nikhil Aggarwal, Subothini Selvendran, Vassilios Vassiliou, Educational Case: A 57-year-old man with chest pain, Oxford Medical Case Reports , Volume 2016, Issue 4, April 2016, Pages 62–65, https://doi.org/10.1093/omcr/omw008

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This is an educational case report including multiple choice questions and their answers. For the best educational experience we recommend the interactive web version of the exercise which is available via the following link: http://www.oxfordjournals.org/our_journals/omcr/ec01p1.html

A 57 year-old male lorry driver, presented to his local emergency department with a 20-minute episode of diaphoresis and chest pain. The chest pain was central, radiating to the left arm and crushing in nature. The pain settled promptly following 300 mg aspirin orally and 800 mcg glyceryl trinitrate (GTN) spray sublingually administered by paramedics in the community. He smoked 20 cigarettes daily (38 pack years) but was not aware of any other cardiovascular risk factors. On examination he appeared comfortable and was able to complete sentences fully. There were no heart murmurs present on cardiac auscultation. Blood pressure was 180/105 mmHg, heart rate was 83 bpm and regular, oxygen saturation was 97%.

What is the most likely diagnosis?

An ECG was requested and is shown in figure 1.

How would you manage the patient? (The patient has already received 300 mg aspirin).

30 minutes later the patient's chest pain returned with greater intensity whilst waiting in the emergency department. Now, he described the pain as though “an elephant is sitting on his chest”. The nurse has already done an ECG by the time you were called to see him. This is shown in figure 2.

ECG on admission.

ECG 30 minutes after admission.

What would be the optimal management for this patient?

He was taken to the catheterization lab where the left anterior descending coronary artery (LAD) was shown to be completely occluded. Following successful percutaneous intervention and one drug eluding stent implantation in the LAD normal flow is restored (Thrombosis in myocardial infarction, TIMI = 3). 72 hours later, he is ready to be discharged home. The patient is keen to return to work and asks when he could do so.

When would you advise him that he could return to work?

One week later, he receives a letter informing him that he is required to attend cardiac rehabilitation. The patient is confused as to what cardiac rehabilitation entails, although he does remember a nurse discussing this with him briefly before he was discharged. He phones the hospital in order to get some more information.

Which of the following can be addressed during cardiac rehabilitation?

A - Acute coronary syndrome

Although the presentation could be attributable to any of the above differential diagnoses, the most likely etiology given the clinical picture and risk factors is one of cardiac ischemia. Risk factors include gender, smoking status and age making the diagnosis of acute coronary syndrome the most likely one. The broad differential diagnosis in patients presenting with chest pain has been discussed extensively in the medical literature. An old but relevant review can be found freely available 1 as well as more recent reviews. 2 , 3

C - Atorvastatin 80 mg, Clopidogrel 300 mcg, GTN 500 mcg, Ramipril 2.5 mg,

In patients with ACS, medications can be tailored to the individual patient. Some medications have symptomatic benefit but some also have prognostic benefit. Aspirin 4 , Clopidogrel 5 , Atenolol 6 and Atorvastatin 7 have been found to improve prognosis significantly. ACE inhibitors have also been found to improve left ventricular modeling and function after an MI. 8 , 9 Furthermore, GTN 10 and morphine 11 have been found to be of only significant symptomatic benefit.

Oxygen should only to be used when saturations <95% and at the lowest concentration required to keep saturations >95%. 12

There is no evidence that diltiazem, a calcium channel blocker, is of benefit. 13

His ECG in figure 1 does not fulfil ST elevation myocardial infarction (STEMI) criteria and he should therefore be managed as a Non-STEMI. He would benefit prognostically from beta-blockade however his heart rate is only 42 bpm and therefore this is contraindicated. He should receive a loading dose of clopidogrel (300 mg) followed by daily maintenance dose (75 mg). 14 , 15 He might not require GTN if he is pain-free but out of the available answers 3 is the most correct.

D - Proceed to coronary angiography

The ECG shows ST elevation in leads V2-V6 and confirms an anterolateral STEMI, which suggests a completely occluded LAD. This ECG fulfils the criteria to initiate reperfusion therapy which traditionally require one of the three to be present: According to guidance, if the patient can undergo coronary angiography within 120 minutes from the onset of chest pain, then this represents the optimal management. If it is not possible to undergo coronary angiography and potentially percutaneous intervention within 2 hours, then thrombolysis is considered an acceptable alternative. 12 , 16

≥ 1 mm of ST change in at least two contiguous limb leads (II, III, AVF, I, AVL).

≥ 2 mm of ST change in at least two contiguous chest leads (V1-V6).

New left bundle branch block.

GTN and morphine administration can be considered in parallel but they do not have a prognostic benefit.

E - Not before an exercise test

This patient is a lorry driver and therefore has a professional heavy vehicle driving license. The regulation for driving initiation in a lorry driver following a NSTEMI/ STEMI may be different in various countries and therefore the local regulations should be followed.

In the UK, a lorry driver holds a category 2 driving license. He should therefore refrain from driving a lorry for at least 6 weeks and can only return to driving if he completes successfully an exercise evaluation. An exercise evaluation is performed on a bicycle or treadmill. Drivers should be able to complete 3 stages of the standard Bruce protocol 17 or equivalent (e.g. Myocardial perfusion scan) safely, having refrained from taking anti-anginal medication for 48 hours and should remain free from signs of cardiovascular dysfunction during the test, notably: angina pectoris, syncope, hypotension, sustained ventricular tachycardia, and/or electrocardiographic ST segment shift which is considered as being indicative of myocardial ischemia (usually >2 mm horizontal or down-sloping) during exercise or the recovery period. 18

For a standard car driving license (category 1), driving can resume one week after successful intervention providing that no other revascularization is planned within 4 weeks; left ventricular ejection fraction (LVEF) is at least 40% prior to hospital discharge and there is no other disqualifying condition.

Therefore if this patent was in the UK, he could restart driving a normal car one week later assuming an echocardiogram confirmed an EF > 40%. However, he could only continue lorry driving once he has passed the required tests. 18

E - All of the above

Cardiac rehabilitation bridges the gap between hospitals and patients' homes. The cardiac rehabilitation team consists of various healthcare professions and the programme is started during hospital admission or after diagnosis. Its aim is to educate patients about their cardiac condition in order to help them adopt a healthier lifestyle. This includes educating patients' about their diet, exercise, risk factors associated with their condition such as smoking and alcohol intake and finally, about the medication recommended. There is good evidence that adherence to cardiac rehabilitation programmes improves survival and leads to a reduction in future cardiovascular events.​ 19 , 20

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Sharpe N , Smith H , Murphy J , Hannan S . Treatment of patients with symptomless left ventricular dysfunction after myocardial infarction . The Lancet . 1988 ; 331 (8580) : 255 – 259 . http://www.sciencedirect.com/science/article/pii/S0140673688903479 .

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Case study 1: acute myocardial infarction

Sep 12, 2014

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Case study 1: acute myocardial infarction. Megan Fuchs Good Sam Dietetic Intern January 5, 2012. Patient Profile Personal Information. 46 year old white male Lives in Cincinnati, OH with wife, daughter, and grandson Leads a physically active lifestyle

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• kcal intake
• current admission
• high blood pressure
• diet education low sodium

Presentation Transcript

Case study 1: acute myocardial infarction Megan Fuchs Good Sam Dietetic Intern January 5, 2012

Patient ProfilePersonal Information • 46 year old white male • Lives in Cincinnati, OH with wife, daughter, and grandson • Leads a physically active lifestyle • Works in maintenance – constant movement • Lifts weights and swims regularly • No ethnic or religious considerations

Patient ProfileAdmission • JD presented to the Western Ridge ER with complaints of chest pain, N/V, and diaphoresis • Found to be having an acute inferior myocardial infarction (MI) • Immediately transferred to GSH ER • At GSH, doctors confirmed the diagnosis of an acute inferior MI based on • EKG results consistent with MI • Noted sinus arrhythmia • Rate of 89 • Marked segment elevation in inferior leads

Patient profilePast medical History • Splenectomy(as a child, unknown reason for removal) • Surgical removal of the spleen due to rupture, enlargement, certain blood disorders, cancer, infections, or non-cancerous tumors • Spleen is an important part of fighting infection – filters damaged red blood cells • Complications may include hemorrhage, blood clots, infection, or injury to other organs • Hypertension(HTN) • High blood pressure • Diagnosed when ones blood pressure is 140/80 mmHg • Factors affecting BP include amount of water and salt in the body; function of the kidneys, nervous system, and blood vessels • Increased risk of developing HTN if one is obese, stressed/anxious, high salt diet, family history, diabetes, smoker, or African American

Patient ProfileFamily History Very strong history of heart failure

Patient profileHealth History • Generally sleeps well, 6-8 hours a night • Physically Active Lifestyle • Maintenance worker – uses stairs, walks to and from buildings • Lifts weights and swims 3-4 times/week • Non-smoker • Occasionally drinks alcohol • No substance abuse

Patient ProfileHealth History • Height: 5’9” • Weight: 267.7 lb • Weight history: 5 lb weight gain/loss throughout the year • No large amount of weight loss or gain • Appetite • Prior to admission – very good appetite, enjoys all foods but eats very little vegetables • JD and his wife enjoy shopping and cooking together • During hospital stay – appetite improved but was initially very poor

Patient profilehealth history • No dental problems • No chewing or swallowing problems • Normal digestion • Elimination – regular bowel movements

Disease BackgroundAcute Inferior Myocardial infarction • Myocardial Infarction or Heart Attack • Occurs when blood flow to part of the heart is blocked resulting in damage or death to the muscle • Usually caused by a blood clot or plaque formation blocking the coronary artery, which supplies the heart with oxygen and blood

Disease BackgroundPathophysiology/etiology • Most common etiologic factor: presence of atherosclerotic plaque blocking the coronary arteries • Plaque leads to the disruption of blood flow through the coronary arteries to the heart • Size of the thrombus determines the percent of blockage, ultimately determining the extent of damage • Decreased blood flow for an amount of time can trigger a process known as ischemic cascade • Causing the heart muscle to die and potentially resulting in cardiac arrhythmia

Disease BackgroundSymptoms • Most often characterized by • Chest pain • Tightness in chest • Feeling of heaviness in the chest area • Nausea • Vomiting • SOB • Sweating • Often mistaken for heart burn or indigestion during initial onset • Usually chest pain or tightness will last longer than 20 minutes and increase in intensity

Medical DiagnosisTreatment • Initial Treatment • Nitroglycerin or morphine to numb chest pain • Angioplasty for stent placement to unclog artery – most common emergency treatment • Drug therapy to break apart clots – thrombolytic therapy • Open heart surgery – most severe cases • After initial treatment • Medication to help protect the heart from future cardiovascular events – blood thinner, beta-blocker, or ACE inhibitor • Lifestyle changes • Slowly incorporating exercise • Changing dietary habits • Maintaining control of BP, blood sugar, and cholesterol levels

Disease BackgroundNutritional Intervention Low sodium, low fat, low cholesterol ≤ 30% total kcal from fat – less than 1/3 of those kcal should be saturated 200 mg/day cholesterol Sodium Weigh loss if overweight should be stressed

Disease BackgroundEvidenced Based Research • The New England Journal of Medicine • Goal: to determine if salt reduction in diet would decrease cardiovascular disease • The effects of salt reduction in association with CVD was compared • Decrease in cost of HTN medication was determined • Results • Reducing dietary salt to 3gm a day would reduce new cases of • CHD by 60,000-120,000 • MI by 54,000-99,000 • Stroke by 32,000-66,000 • Medical costs related to CVD would decrease by 10 billion to 24 billion dollars annually

Disease BackgroundPrognosis • Usually, patients without complications can return to normal activity – slowly! • The prognosis is dependent on how much of the heart muscle was damaged • Amount of damage will determine how fast one returns to normal activities • Level of damage may cause arrhythmia, valve problems, or heart rupture • If the heart is no longer able to pump blood as well as it used to, heart failure may be a concern

Application to patient • Initial Diagnosis: Acute Inferior Myocardial Infarction • November 20, 2011 • Symptoms: Chest pain (7 out of 10), nausea, vomiting, and diaphoresis • Sinus arrhythmia, marked segment elevation of inferior leads • Symptoms lasting 2 hr total • JD had a very good understanding of his diagnosis • Although discouraged because he lead an active lifestyle • Unaware of unhealthy eating habits in relation to diagnosis • Connection to strong family history of heart disease

Current Admission • Diagnosis • Acute Inferior Myocardial Infarction • Diagnostic procedures • Metabolic panel, chest panel, and complete blood count • Echocardiogram showed mild decrease in the left atrium, left ventricular function decreased, ejection factor of 45-50%, and trace mitral regurgitation • Chest x-ray found the trachea, heart, and mediastinal structures to be normal, along with clear lungs and pleural spaces

Current admission • Diagnostic procedures cont. • Coronary angiography summary noted • dominant right system single vessel disease • left ventriculography demonstrated severe inferior hypokinesis • The right coronary artery was proximally occluded and enlarged with no collateralization • Initially JD’s cardiac enzymes were • CK: 252 • MB: 4.4 • Troponin: 0.01

Current AdmissionTreatment Stent placement to the right coronary artery occlusion JD was started on the beta-blocker Carvedilol to control his hypertension and treat his valve dysfunction in combination with a statin JD was also prescribed plavix and advised to take an aspirin to help avoid future cardiovascular events

Current AdmissionMedications • Chewable Aspirin • Colace • Coreg • Heparin • Lipitor • Maalox • Morphine • Nitroglycerin • Plavix • Prinivil • Tylenol • Xanax • Zofran

Nutrition Care ProcessNutrition Assessment • Current Diet Order • Cardiac: low fat/cholesterol, 3 gram Na, 0 caffeine • Diet History • Prior to admission JD did not follow any specific diet restrictions; 3 meals a day with an evening snack • Fast food (White Castle, Skyline), Sit down restaurants (Applebee’s 1-2 times/week), and home cooked meals (~4 times/week) • Ate very little vegetables; liked apples, oranges, and grapes; drank 2% milk • Both JD and his wife cook and grocery shop together • JD expressed interest in learning new recipes and substituting items to make each meal more heart healthy

Nutrition Care ProcessNutrition Assessment • 24 hour recall • 25% po intake at breakfast – couple bites of low sodium scrambled eggs and whole wheat english muffin with a small amount of jelly, few sips of orange juice • 100% po intake at lunch – meatloaf, red skin mashed potatoes, vegetable medley (corn, red peppers, green beans), dinner roll, and 4 oz apple juice • 100% po intake at dinner – oven baked chicken, sliced potatoes, vegetables (yellow squash, carrots, and peppers), and 8 oz skim milk • JD avoided his deserts because he is not big on sweets

Nutrition Care ProcessNutrition Assessment • JD had no prior MNT • Prior to admission JD clearly stated he ate few, if any vegetables and likes some fruits. Also, most of his meals during the week consist of fast food. JD’s diet is mainly high fat, high sodium foods • While in the hospital, JD received well balanced meals, and surprisingly he ate the vegetables! • Level of nutritional risk: moderate risk due to high-risk diagnosis and obesity (167% IBW)

Nutrition Care ProcessNutritionAssessment Anthropometrics Biochemical Labs • Height: 5’9” • Weight: 267.7 lb (122 kg) • IBW: 160 lb ± 10% • %IBW: 167% • ABW: 187 lb (85 kg) • Usual wt: 250 lb (114 kg) • % weight change: +7% • BMI: 39.45 kg/m2

Nutrition care processnutrition assessment Macronutrient Needs Calories: 2125 kcal (25 kcal/kg ABW) Protein: 68-85 gm (0.8-1.0 gm/kg ABW) Carbohydrates: 292 gm/day (55% total kcal) Fat: 71 gm/day (30% total kcal) *16.5 gm saturated fat/day (7% total fat)

Nutrition Care ProcessNutrition Diagnosis • Nutrition Diagnosis • NC-3.3 Overweight/obesity • PES Statement • Overweight/obesity related to excessive kcal intake as evidenced by 167% IBW and a BMI of 39.45 kg/m2 • Goals included appropriate weight loss, appropriate oral intake, and appropriate kcal intake • Recommendation • A critical aspect of JD’s recovery is a decrease in weight and a more restrictive diet than he was used to – diet education is key in preventing future cardiac events

Nutrition Care ProcessNutrition Intervention • Plan • Limit foods high in fat, cholesterol, and sodium • Cholesterol intake should be < 200 mg/day • Total percent of fat from kcal should be ≤ 30% • Increase MUFA and decrease saturated fats (7% of kcal/day) • Decreasing total kcal intake to obtain appropriate weight loss • Implement • Provided JD with a list of heart healthy foods • Explained what foods were high in fat, cholesterol, and sodium • Reviewed sources of saturated fat and MUFA • Explained how to read a nutrition fact label • Provided tips eating out • Diet education – low sodium, low fat, low cholesterol – and weight loss are the most important nutrition interventions for JD.

Nutrition Care ProcessMonitoring and Evaluation • While in the hospital JD was receiving a cardiac diet per MD order • Extensive diet education was provided • JD expressed great intentions to follow a low fat, low cholesterol, low sodium diet at home • Monitoring JD’s progress • Keeping track of his daily sodium, cholesterol, and fat intake – comparing day to day • Writing down times a week he eats out and what he ate

Summary • 46 year old male living a moderately active lifestyle • PMH: hypertension and splenectomy • Current medical diagnosis: acute inferior myocardial infarction • Stent placement, EF 45-50% • Medications: carvedilol, aspirin, plavix, statin • Cardiac diet per MD • Educated on importance of low sodium, low fat, low cholesterol diet, along with weight loss • Encouraged to keep records of fat, cholesterol, and sodium for self monitoring

References • Mayo Foundation for Medical Education and Research. Splenectomy. Available at http://www.mayoclinic.com/health/splenectomy/MY01271. Accessed 11/30/2011. • Dugdale, DC. PubMed Health. Hypertension. Available at http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001502/. Accessed 11/30/2011. • Chen, MA. PubMed Health. Heart Attack. Available at http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001246/. Accessed 11/30/2011. • Khera, AV. Cuchel, M. de la Llera-Moya, M. Rodrigues, A. Burke, MF. Jafri, K. French, BC. Phillips, JA. Muchsavage, ML. Wilensky, RL. Mohler, ER. Rothblat, GH. Rader, DJ. Cholesterol Efflux Capacity, High-Density Lipoprotein Function, and Atherosclerosis. N Engl J Med 2011; 364:127-35. • Siri-Tarino, PW. Sun, Q. Hu, FB. Krauss, RM. Meta-analysis of prospective cohort studies evaluating the association of saturated fat with cardiovascular disease. Am J ClinNutr 2010; 91:535-46.

References • Bibbins-Domingo, K. Chertow, GM. Coxson, PG. Moran, A. Lightwood, JM. Pletcher, MJ. Goldman, L. Projected Effect of Dietary Salt Reductions on Future Cardiovascular Disease. N Engl J Med 2010; 362:590-9. • TriHealth, Inc. Eating with your Hearts Consent. The Heart and Vascular Center. • Lee, CD. Jacobs, DR. Schreiner, PJ. Iribarren, C. Hankinson, A. Abdominal Obesity and Coronary Artery Calcification in Young Adults: the Coronary Artery Risk Development in Young Adults (CARDIA) Study. Am J ClinNutr 2007; 86:48-54. • Martin, T. The Normal Range for Creatine Kinase Blood Test. Available at http://www.brighthub.com/science/medical/articles/75706.aspx. Accessed 11/30/2011. • The American Association for Clinical Chemistry. CK-MD, The Test. Available at http://labtestsonline.org/understanding/analytes/ckmb/tab/test. Accessed 11/30/2011. • Pronsky, ZM. Crowe, SR JP. Food Medication Interactions, 16th edition. 2010; p. 3-339. • Khan, S. Myocardial Infarction Pathophysiology. Available at http://www.buzzle.com/articles/myocardial-infarction-pathophysiology.html. Accessed 12/30/11.

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Patient Case Presentation

Patient presentation.

Mr. Smith is a 60-year-old Caucasian male, who presents with 8/10 chest pain after working out. He just quit smoking and started a new workout and diet program after recently retiring. He has noticed some chest and shoulder discomfort with working out that usually resolves with rest, but decided to come to the emergency department because this episode was unrelenting and more severe. Mr. Smith describes his current pain as severe and sharp, and also complains of nausea and shortness of breath. Vital signs are HR: 110 BP: 150/90 RR: 30 Temp 97.6 O2 Sat: 92% on 2L nasal cannula, EKG shows ST segment elevation in leads II, III and AVf. Labs were drawn, including an elevated troponin (4.23 ng/ml), and slightly elevated white blood cell count (13.6 × 10 9 /L) .

Past Medical History

Type II diabetes (age 47), dyslipidemia (age 33), atherosclerosis (age 52), hypertension (age 49), obesity (age 33), viral pneumonia (age 29), hiatal hernia (age 28), peptic ulcer disease (age 41)

Family Medical History

Mother (deceased) – atrial fibrillation (diagnosed at age 45), died of MI (age 65)

Father (83) – obesity, type II diabetes (diagnosed at 50), COPD (diagnosed at 55)

Social History

Smoker (20 pack years), worked in an office sitting at a desk his whole career (35 years), recently began working out at his local gym since retiring this year.

Myocardial Infarction (MI) Case Study (45 min)

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Definition of Myocardial Infarction (MI)

Myocardial infarction, commonly known as a heart attack, is a critical medical event that occurs when the blood supply to the heart muscle is severely reduced or completely blocked. It is a leading cause of death worldwide and a significant public health concern.

Introduction to Myocardial Infarction (MI)

This nursing case study aims to provide a comprehensive understanding of myocardial infarction by delving into its various aspects, including its pathophysiology, risk factors, clinical presentation, diagnostic methods, and management strategies. Through the exploration of a fictional patient’s journey, we will shed light on the intricate nature of this life-threatening condition and highlight the importance of early recognition and intervention.

Background and Significance of Myocardial Infarction

Myocardial infarction is a sudden and often catastrophic event that can have profound consequences on an individual’s health and well-being. Understanding its underlying mechanisms and risk factors is essential for healthcare professionals, as timely intervention can be life-saving. This case study not only serves as a learning tool but also emphasizes the critical role of medical practitioners in identifying and managing myocardial infarctions promptly.

Pathophysiology of Myocardial Infarction

A crucial aspect of comprehending myocardial infarction is exploring its pathophysiology. We will delve into the intricate details of how atherosclerosis, the buildup of plaque in coronary arteries, leads to the formation of blood clots and the subsequent interruption of blood flow to the heart muscle. This disruption in blood supply triggers a cascade of events, ultimately resulting in the death of cardiac cells.

Risk Factors of Myocardial Infarction

Understanding the risk factors associated with myocardial infarction is vital for prevention and early detection. This case study will examine both modifiable and non-modifiable risk factors, including age, gender, family history, smoking, high blood pressure, diabetes, and high cholesterol levels. Recognizing these risk factors is instrumental in developing effective strategies for prevention and risk reduction.

Clinical Presentation Myocardial Infarction

Recognizing the signs and symptoms of myocardial infarction is crucial for timely intervention. We will present a fictional patient’s experience, illustrating the typical clinical presentation, which often includes chest pain or discomfort, shortness of breath, nausea, lightheadedness, and diaphoresis. Through this patient’s journey, we will highlight the importance of accurate symptom assessment and prompt medical attention.

Diagnostic Methods for Myocardial Infarction

Modern medicine offers various diagnostic tools to confirm a myocardial infarction swiftly and accurately. This case study will explore these diagnostic methods, such as electrocardiography (ECG), cardiac biomarkers, and imaging techniques like coronary angiography. By understanding these diagnostic modalities, healthcare professionals can make informed decisions and initiate appropriate treatments promptly.

Management Strategies for Myocardial Infarction

The management of myocardial infarction involves a multidisciplinary approach, including medication, revascularization procedures, and lifestyle modifications. We will discuss the fictional patient’s treatment plan, emphasizing the importance of reestablishing blood flow to the affected heart muscle and preventing further complications.

Nursing Case Study for Myocardial Infarction (MI)

Having established a foundational understanding of myocardial infarction, we will now delve deeper into Mr. Salazar’s case, tracing his journey through diagnosis, treatment, and recovery. This in-depth examination will shed light on the real-world application of the principles discussed in the introduction, providing valuable insights into the clinical management of myocardial infarction and its impact on patient outcomes.

Mr. Salazar, a 57-year-old male, arrives at the Emergency Department (ED) with complaints of chest pain that began approximately one hour after dinner while he was working. He characterizes the discomfort as an intense “crushing pressure” located centrally in his chest, extending down his left arm and towards his back. He rates the pain’s severity as 4/10. Upon examination, Mr. Salazar exhibits diaphoresis and pallor, accompanied by shortness of breath (SOB).

What further nursing assessments need to be performed for Mr. Salazar?

• Heart Rate (HR): The number of heartbeats per minute.
• Blood Pressure (BP): The force of blood against the walls of the arteries, typically measured as systolic (during heartbeats) and diastolic (between heartbeats) pressure.
• Respiratory Rate (RR): The number of breaths a patient takes per minute.
• Body Temperature (Temp): The measurement of a patient’s internal body heat.
• Oxygen Saturation (SpO2): The percentage of oxygen in the blood.
• S1: The first heart sound, often described as “lub,” is caused by the closure of the mitral and tricuspid valves.
• S2: The second heart sound, known as “dub,” results from the closure of the aortic and pulmonic valves.
• These sounds provide important diagnostic information about the condition of the heart.
• Clear: Normal, healthy lung sounds with no added sounds.
• Crackles (Rales): Discontinuous, often high-pitched sounds are heard with conditions like pneumonia or heart failure.
• Wheezes: Whistling, musical sounds often associated with conditions like asthma or chronic obstructive pulmonary disease (COPD).
• Pulses refer to the rhythmic expansion and contraction of arteries with each heartbeat. Common pulse points for assessment include the radial artery (wrist), carotid artery (neck), and femoral artery (groin). Evaluating pulses helps assess the strength, regularity, and rate of blood flow.
• Edema is the abnormal accumulation of fluid in body tissues, leading to swelling. It can occur in various body parts and may indicate underlying conditions such as heart failure, kidney disease, or localized injury. Edema assessment involves evaluating the degree of swelling and its location.
• Skin condition (temperature, color, etc.)

What interventions do you anticipate being ordered by the provider?

• Oxygen therapy involves administering oxygen to a patient to increase the level of oxygen in their blood. It is used to treat conditions such as respiratory distress, and hypoxia (low oxygen levels), and to support patients with breathing difficulties.
• Nitroglycerin is a medication used to treat angina (chest pain) and to relieve symptoms of heart-related conditions. It works by relaxing and widening blood vessels, which improves blood flow to the heart, reducing chest pain.
• Aspirin is a common over-the-counter medication and antiplatelet drug. In the context of myocardial infarction (heart attack), it is often administered to reduce blood clot formation, potentially preventing further blockage in coronary arteries.
• A 12-lead EKG is a diagnostic test that records the electrical activity of the heart from 12 different angles. It provides information about the heart’s rhythm, rate, and any abnormalities, helping diagnose conditions like arrhythmias, heart attacks, and ischemia.
• Cardiac enzymes are proteins released into the bloodstream when heart muscle cells are damaged or die, typically during a heart attack. Measuring these enzymes, such as troponin and creatine kinase-MB (CK-MB), helps confirm a heart attack diagnosis and assess its severity.
• A chest X-ray is a diagnostic imaging procedure that creates images of the chest and its internal structures, including the heart and lungs. It is used to identify issues like lung infections, heart enlargement, fluid accumulation, or fractures in the chest area.
• Possibly an Echocardiogram

Upon conducting a comprehensive assessment, it was observed that the patient exhibited no signs of jugular vein distention (JVD) or edema. Auscultation revealed normal heart sounds with both S1 and S2 present, while the lungs remained clear, albeit with scattered wheezes. The patient’s vital signs were recorded as follows:

• BP 140/90 mmHg SpO 2 90% on Room Air
• HR 92 bpm and regular Ht 173 cm
• RR 32 bpm Wt 104 kg
• Temp 36.9°C

The 12-lead EKG repor t indicated the presence of “Normal sinus rhythm (NSR) with frequent premature ventricular contractions (PVCs) and three- to four-beat runs of ventricular tachycardia (VT).” Additionally, there was ST-segment elevation in leads I, aVL, and V2 through V6 (3-4mm), accompanied by ST-segment depression in leads III and aVF.

Cardiac enzyme levels were collected but were awaiting results at the time of assessment. A chest x-ray was also ordered to provide further diagnostic insights.

In response to the patient’s condition, the healthcare provider prescribed the following interventions:

• Aspirin: 324 mg administered orally once.
• Nitroglycerin: 0.4 mg administered sublingually (SL), with the option of repeating the dose every five minutes for a maximum of three doses.
• Morphine: 4 mg to be administered intravenously (IVP) as needed for unrelieved chest pain.
• Oxygen: To maintain oxygen saturation (SpO2) levels above 92%.

These interventions were implemented to address the patient’s myocardial infarction (heart attack) and alleviate associated symptoms, with a focus on relieving chest pain, improving oxygenation, and closely monitoring vital signs pending further diagnostic results.

What intervention should you, as the nurse, perform right away? Why?

• Apply oxygen – this can be done quickly and easily and can help to prevent further complications from low oxygenation.
• Oxygen helps to improve oxygenation as well as to decrease myocardial oxygen demands.
• Often it takes a few minutes or more for medications to be available from the pharmacy, so it makes sense to take care of this intervention first.
• ABC’s – breathing/O 2 .

What medication should be the first one administered to this patient? Why? How often?

• Nitroglycerin 0.4mg SL – it is a vasodilator and works on the coronary arteries. The goal is to increase blood flow to the myocardium. If this is effective, the patient merely has angina. However, if it is not effective, the patient may have a myocardial infarction.
• Aspirin should also be given, but it is to decrease platelet aggregation and reduce mortality. While it can somewhat help prevent the worsening of the blockage, it does little for the current pain experienced by the patient.
• Morphine should only be given if the nitroglycerin and aspirin do not relieve the patient’s chest pain.

What is the significance of the ST-segment changes on Mr. Salazar's 12-lead EKG?

• ST-segment changes on a 12-lead EKG indicate ischemia (lack of oxygen/blood flow) or infarction (death of the muscle tissue) of the myocardium (heart muscle). 
• This indicates an emergent situation. The patient’s coronary arteries are blocked and need to be reopened by pharmacological (thrombolytic) or surgical (PCI) intervention.
• Time is tissue – the longer the coronary arteries stay blocked, the more of the patient’s myocardium that will die. Dead heart tissue doesn’t beat.

Mr. Salazar’s chest pain was unrelieved after three (3) doses of sublingual nitroglycerin (NTG). Morphine 5 mg intravenous push (IVP) was administered, as well as 324 mg chewable baby aspirin. His pain was still unrelieved at this point

Mr. Salazar’s cardiac enzyme results were as follows:

Troponin I 3.5 ng/mL

Based on the results of Mr. Salazar's labs and his response to medications, what is the next intervention you anticipate? Why?

• Mr. Salazar needs intervention. He will either receive thrombolytics or a heart catheterization (PCI).
• Based on the EKG changes, elevated Troponin level, and the fact that his symptoms are not subsiding, it’s possible the patient has a significant blockage in one or more of his coronary arteries. 
• It seems as though it may be an Anterior-Lateral MI because ST elevation is occurring in I, aVL, and V 2 -V 6 .

Mr. Salazar was taken immediately to the cath lab for a Percutaneous Coronary Intervention (PCI). The cardiologist found a 90% blockage in his left anterior descending (LAD) artery. A stent was inserted to keep the vessel open.

What is the purpose of Percutaneous Coronary Intervention (PCI), also known as a heart catheterization?

• A PCI serves to open up any coronary arteries that are blocked. First, they use contrast dye to determine where the blockage is, then they use a special balloon catheter to open the blocked vessels. 
• If that doesn’t work, they will place a cardiac stent in the vessel to keep it open.[ /faq]

[faq lesson="true" blooms="Application" question="What is the expected outcome of a PCI? What do you expect to see in your patient after they receive a heart catheterization?"]

• Blood flow will be restored to the myocardium with minimal residual damage.
• The patient should have baseline vital signs, relief of chest pain, normal oxygenation status, and absence of heart failure symptoms (above baseline).
• The patient should be able to ambulate without significant chest pain or SOB.
• The patient should be free from bleeding or hematoma at the site of catheterization (often femoral, but can also be radial or (rarely) carotid.

Mr. Salazar tolerated the PCI well and was admitted to the cardiac telemetry unit for observation overnight. Four (4) hours after the procedure, Mr. Salazar reports no chest pain. His vital signs are now as follows:

• BP 128/82 mmHg SpO 2 96% on 2L NC
• HR 76 bpm and regular RR 18 bpm
• Temp 37.1°C

Mr. Salazar will be discharged home 24 hours after his arrival to the ED and will follow up with his cardiologist next week. 

What patient education topics would need to be covered with Mr. Salazar?

• He should be taught any dietary and lifestyle changes that should be made.
• Diet – low sodium, low cholesterol, avoid sugar/soda, avoid fried/processed foods.
• Exercise – 30-45 minutes of moderate activity 5-7 days a week, u nless instructed otherwise by a cardiologist. This will be determined by the patient’s activity tolerance – how much can they do and still be able to breathe and be pain-free?
• Stop smoking and avoid caffeine and alcohol.
• Medication Instructions
• Nitroglycerin – take one SL tab at the onset of chest pain. If the pain does not subside after 5 minutes, call 911 and take a second dose. You can take a 3rd dose 5 minutes after the second if the pain does not subside. Do NOT take if you have taken Viagra in the last 24 hours.
• Aspirin – take 81 mg of baby aspirin daily
• Anticoagulant – the patient may be prescribed an anticoagulant if they had a stent placed.  They should be taught about bleeding risks.
• When to call the provider – CP unrelieved by nitroglycerin after 5 minutes. Syncope. Evidence of bleeding in stool or urine (if on anticoagulant). Palpitations, shortness of breath, or difficulty tolerating activities of daily living.

Linchpins for Myocardial Infarction Nursing Case Study

In summary, Mr. Salazar’s case highlights the urgency of recognizing and responding to myocardial infarction promptly. The application of vital signs, EKG, cardiac enzymes, and medications like aspirin, nitroglycerin, and morphine played a pivotal role in his care. Diagnostic tools like echocardiography and chest X-rays contributed to a comprehensive evaluation.

Nurses must remain vigilant and compassionate in such emergencies. This case study emphasizes the importance of adhering to best practices in the assessment, diagnosis, and management of myocardial infarction, with the ultimate goal of achieving favorable patient outcomes.

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Nursing Case Studies

This nursing case study course is designed to help nursing students build critical thinking.  Each case study was written by experienced nurses with first hand knowledge of the “real-world” disease process.  To help you increase your nursing clinical judgement (critical thinking), each unfolding nursing case study includes answers laid out by Blooms Taxonomy  to help you see that you are progressing to clinical analysis.We encourage you to read the case study and really through the “critical thinking checks” as this is where the real learning occurs.  If you get tripped up by a specific question, no worries, just dig into an associated lesson on the topic and reinforce your understanding.  In the end, that is what nursing case studies are all about – growing in your clinical judgement.

Nursing Case Studies Introduction

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Metabolic/Endocrine Nursing Case Studies

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Case Report

Acute coronary syndrome, associated data.

The paramedics brought a 60-year-old man to the emergency department after a sudden onset of shortness of breath with a subsequent drop in the Glasgow Coma Scale (GCS). On arrival the patient looked peri-arrest. His O 2 saturations were 84% on 15 L of oxygen. He had gasping breathing with a completely silent chest and the GCS was 6/15 (E=1, V=1, M=4). The blood gas revealed type-2 respiratory failure. The chest X-ray was unremarkable and ECG was not indicative for cardiac catheterisation lab activation. Bedside shock scan was done which showed global hypokinesia of the left ventricle. In spite of unconvincing ECG and chest X-ray, an acute cardiac event was diagnosed in view of an abnormal bedside echo. The patient was transferred to the cardiac catheterisation lab for urgent percutaneous coronary intervention which revealed critical stenosis of the left main stem coronary artery, which was successfully stented. The patient had a good recovery from the life-threatening event.

Patients with undifferentiated shock can be a real challenge for the Emergency Physician. To diagnose the underlying cause in a shocked patient in a timely manner is vital as the treatment options may be completely different and are also time critical. It is imperative for emergency physicians to equip themselves with ultrasound skills as it can play a key role in the patient's management.

This case is an excellent example of the importance of bedside ultrasound scan utilisation. The patient's presentation was very atypical for an acute coronary event. His bedside ECG ( figure 1 ) and chest X-ray (CXR; figure 2 ) were not helpful in the diagnosis until an ultrasound scan ( video 1 ) revealed a significant left ventricle wall motion abnormality and explained the patient's condition.

ECG showing sinus tachycardia with QRS at upper normal limit of 120 ms. The voltage criteria for left ventricular hypertrophy is met. No features to suggest acute ST-elevation myocardial infarction are obvious.

Chest anteroposterial supine X-ray not showing any major areas of airspace opacification or pneumothorax.

Video 1

A sub-xiphoid view of heart during bedside ultrasound shock scan shows almost globally akinetic left ventricle .Right ventricle seems to be contracting normally. No pericardial fluid was seen.

Case presentation

Our patient was a 60-year-old man who was brought to the emergency department (ED) by paramedics after a sudden onset of shortness of breath.

On scene when attended by the paramedics the patient was in significant respiratory distress and was diaphoretic. There was no history of chest pain. On arrival to the ED, he was unresponsive but the airway was patent. The patient's breathing effort was very poor and he was gasping. His trachea was central and chest was completely silent. His breathing was supported initially with a bag valve mask and then subsequently the patient was intubated in view of his low Glasgow Coma Scale (GCS). He was easy to ventilate and the chest movements were bilateral and equal. His first blood pressure reading was 170/110 mm Hg and pulse rate was about 120/min. His neck veins were not engorged and he had equal blood pressure in both arms. His GCS was 6/15 (E=1, V=1, M=4). The rest of the examination was unremarkable. We could not figure out the cause of the patient's acute deterioration after completing the primary survey.

The patient was continuously monitored and serial ECGs were carried out. The ECGs were discussed with the Cardiology Registrar who was not convinced of any acute cardiac event.

The patient had no significant medical or surgical history and was not on any medications.

Investigations

Routine bloods in the ED were:

• Haemoglobin 158 g/L
• White cell count 17.1×10 9 /L
• Sodium 136 mmol/L
• Potassium 4 mmol/L
• Urea 6.1 mmol/L
• Creatinine 97 μmol/L
• Estimated glomerular filtration rate 73 mL/min/L.73 m 2
• C reactive protein <5 mg/L
• Troponin I 115 μg/L
• International normalised ratio 1.0
• D-dimer 0.95 μg/L
• Arterial blood gas: pH 6.98, pCO 2 16.02 kPa, pO 2 21.7 kPa, HCO 3 27.8 mmol/L, base excess −7.5, lactate 2.7.

CXR showed no significant pathology.

ECG showed sinus tachycardia with left ventricular hypertrophy.

Focused bedside cardiac ultrasound scan 1 and shock scan 2 conducted by the ED Registrar showed global hypokinesia of the left ventricle.

Official echo performed later by the cardiologist showed severe systolic dysfunction and apical thrombus.

The coronary angiogram revealed severe ostial stenosis of the left main coronary artery.

Differential diagnosis

A patient with low GCS, shortness of breath and type-2 respiratory failure may have wide differentials like life-threatening asthma, tension pneumothorax, acute cardiac events or massive pulmonary embolism. Treatment of each is quite different and time critical. An early shock scan using ultrasound helped us narrow our differential towards a cardiac pathology.

On the way to hospital, paramedics had given the patient salbutamol and ipratropium nebulisation, intravenous hydrocortisone (100 mg) and intravenous furosemide (40 mg).

In the ED, initially the patient's breathing was supported with bag-valve-mask ventilation with 15 L of O 2 . The patient was also given intravenous salbutamol 0.5 mg bolus, magnesium sulfate 2 g and 500 mL of 0.9% normal saline.

ITU were consulted to secure the airway. The patient was intubated and transferred to the cardiac catheterisation laboratory for immediate percutaneous coronary intervention (PCI).

Outcome and follow-up

A 4.5×13 mm stent was placed in the left main artery during emergency PCI. Postprocedure, the patient was admitted to the intensive care unit for 1 day and then transferred to the ward for monitoring. After a few days of observation the patient was discharged home with medicines and for follow-up in the cardiology clinic.

We found the patient's presentation very challenging. The patient had no chest pain and had low GCS. His CXR and ECG were non-diagnostic. Atypical presentations in acute coronary syndrome are known phenomenon where there is absence of chest pain. Although some high-risk factors have been identified, 3 for example older age (72.9 years), female gender, non-white race and comorbidities (diabetes, stroke and heart failure); our patient had none of them. The National Registry of Myocardial Infarction 2 database showed that 33% patients did not present with chest pain. 4 Patients with myocardial infarction without chest pain are less quickly diagnosed and treated and have higher adjusted odds of hospital mortality, regardless of whether they have an ST-segment elevation. 5 6 The presence of silent chest is a possible presentation in early stages of cardiogenic shock and has mortality of about 70% due to the difficulty in diagnosis. 7 Although our patient was presented atypically with very little history available as a result of low GCS and non-specific ECG, a quick bedside (see video 1 ) echo which showed a globally hypokinetic left ventricle proved to be a life saver as the right diagnosis was made and critical minutes were saved by not making other unnecessary investigations such as CT of the head.

Bedside ultrasound is widely used by most physicians during the management of trauma patients but its use in the assessment of sick medical patients is still not considered an important diagnostic tool. There is enough evidence 8 to suggest that the use of ultrasound during the initial assessment of sick medical patients can increase the diagnostic accuracy significantly as shown in this case.

Learning points

• Ultrasound is an important tool for emergency and acute care physicians.
• Bedside ultrasound should be performed early during the initial assessment of sick medical patients to diagnose life-threatening emergencies.
• Acute coronary syndrome (ACS) with flash pulmonary oedema can mimic life-threatening asthma and respiratory failure.
• Atypical presentations of ACS should always be kept in mind.

Contributors: Both the authors have dealt with the patient and contributed to the case report.

Competing interests: None.

Patient consent: Obtained.

Provenance and peer review: Not commissioned; externally peer reviewed.