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March 23, 2021 Edward Smith Competency: Coronary Heart Disease Edward

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March 23, 2021 Edward Smith Competency: Coronary Heart Disease Edward.Smith@citytech.cuny.edu General Information: GY is a 70 years old White American male at the emergency department of NYP Medical Center with multiple complications. CC: “I feel weakness and difficulty of breathing”. HPI: GY is a 70 years old male presents to the emergency department with multiple complications. He has not felt well last couple of weeks and lost appetite and lost weight 15 lb in the last month. GY has diabetic nephropathy which has progressed to ESRD for 10 years. He has renal failure and has been on hemodialysis for 5 years (2 times/week). He has history of coronary heart disease for last 10 years, COPD for last 15 years and abnormality in secretion of corticosteroid hormone from birth. He occasionally feels pain in his chest which disappears after taking nitroglycerine sublingual tablet or rest. He complains shortness of breath and becomes weak after walking several blocks. PMH: Ischemic Heart Disease X 10 years and controlled by medication Chronic Obstructive Pulmonary Disease X 15 years and uncontrolled Adrenal insufficiency X from birth FH: Mother died at the age of 90 from diabetes. Father died of heart attach at the age of 75. He has no siblings. SH: Ethanol drinking with 2 beers x daily, he smokes 1 pack of cigarettes daily, he is single and live in government shelter. ROS: None All: NKA Meds: Nitroglycerine SL 0.4 mg prn for chest pain Atenolol 50 mg po qd Levalbuterol neb 0.63 mg tid every 6 hours Ipratropium neb 500 mcg every 6 hours Lipitor 10 mg po daily Prednisone 5 mg po daily Glyburide 10 mg po daily Furosemide 40 mg po daily PE: VS: BP 130/74 P 79 RR 18, T 98ºF, Wt 62 kg, Ht 5’8” CHEST: RRR, no murmur, rales bilaterally chest wall NT. CV: S1 S2 normal, no chest pain, no palpitation, no shortness of breath Abd: No bruits tenderness, no masses. Skin: Rash at lower extremities HEENT: No history of headaches, dysphasia or odonyphasia Mental status: Normal. Labs: Na 135; K 4.3; Cl 102; CO2 24; BUN 27 (H); Scr 2.1 (H); Glu 170 (H); ALT 26; AST 21; total Chol 175; LDL 120; HDL 39; TG 115; Albumin 4.8; Hgb 18; Hct 43% RBC 5.6; WBC 9; Plt 250, A1C 9.0, DST 450. Coronary Heart Disease (CHD) Subjective: GY is a 70 year old male who is suffering from coronary heart disease from last 10 years. He complains weakness and difficulty of breathing. He occasionally feels pain in his chest which disappears after taking nitroglycerine sublingual tablet or rest. He drinks beer and smokes regularly. Objective: Age 70; BP 130/74 P 79 RR 18; ALT 26; AST 21; total Chol 175; LDL 120; HDL 39; TG 115; Hgb 18; Hct 43% RBC 5.6 Assessment: Coronary heart disease (CHD) also known as coronary artery disease (CAD) or ischemic heart disease (IHD). CHD is defined as a lack of oxygen and decreased or no blood flow to the myocardium resulting from coronary artery narrowing or obstruction. CHD may present as an acute coronary syndrome (ACS), which includes unstable angina pectoris and acute myocardial infraction (AMI) associated with EKG changes of either STsegment elevation (STEMI) or non-ST-segment elevation (NSTEMI). CHD may also preent as chronic stable exertional angina, ischemia without symptoms, or ischemia due to coronary artery vasospasm. Coronary blood flow rate determine the oxygen supply capacity to the heart and heart rate, contractility and intramyocardial wall tension determine the oxygen demand to myocardium. Oxygen demand is considered the most important factor because the consequences of CHD usually result from increased demand in the face of a fixed oxygen supply. Increased oxygen demand can occur with exertion, emotional stress which increases sympathetic stimulation and thus heart rate. Aortic stenosis, dilated cardiomyopathy, hypertrophic cardiomyopathy, tachycardia, hyperthyroidism, hypertension, emotional stress, anxiety and hyperthermia are associated with increased oxygen demand. Decreased blood flow to the heart results from atherosclerosis, coronary artery spasm, traumatic injury or embolic events. Conditions that are associated with decreased oxygen supply are aortic stenosis, hypertrophic cardiomyopathy, sickle cell disease, anemia, hypoxemia, hyperviscosity and drugs. The unalterable risk factors for atherosclerosis are gender (male), age (>60 yrs), family history and DM are prominent1. Alterable risk factors for atherosclerosis are smoking, hypertension, obesity, hyperlipidemia, sedentary lifestyle, alcohol consumption etc. Therefore, considering above risk factors it is clear that GY is suffering from ischemic heart disease since he is a male at his 70, he drinks alcohol, he smokes a pack of cigarette daily, he is diabetic and he has hyperlipidemia. Many episodes of ischemia do not cause anginal symptoms. Patients often have chest pain that appear after exertion, cold environment, fright, anger, walking against wind. Symptoms may include a sensation of pressure or burning over the sternum or near it, which often radiates to the left jaw, shoulder and arm. Chest tightness, SOB, DOE, palpitation, lightheadedness nausea/vomiting may also occur. The sensation usually lasts for 30 seconds to 30 minutes and relief in 45 seconds to 5 minutes of taking SL nitroglycerine. Patients with Prinzmetal’s angina secondary to coronary spasm are more likely to experience pain at rest and in the early morning. Unstable angina is stratified into three categories of low, intermediate, or high risk for short term death or nonfatal MI. Features of high risk unstable angina include pain at rest lasting more than 20 minutes, age greater than 75, ST-segment changes and clinical finding of pulmonary edema. So GY’s coronary artery disease is kind of stable angina since the pain disappers after taking nitroglycerin or rest. Diagnosis of ischemic heart disease include the nature and quality of chest pain, precipitating factors, duration, pain radiation, respond to nitroglycerine or rest, existing personal risk factors and detailed family history. Recommended laboratory tests include hemoglobin (to ensure adequate oxygen-carrying capacity), fasting glucose (to exclude diabetes) and fasting lipoprotein panel. The EKG is normal in 50% or more patients with stable angina. Typically ST-T wave changes include depression, ST-segment elevation or Twave inversion. Variant angina is associated with ST-segment elevation whereas silent ischemia may produce elevation or depression. Exercise tolerance testing (ETT) is recommended for patient with an intermediate probability of CAD. Results of ETT correlate well with the likelihood of progression of angina, occurrence AMI and cardiovascular death. Pharmacological stress testing is useful for patient who is unable to exercise. IV dobutamine, adenosine or presantine are able to detect the cardiac ischemia in conjugation with EKG testing. Treatment goal of ischemic heart disease are to prevent MI and death, to reduce symptoms of angina and occurrence of ischemia and thereby increasing a patient’s quality of life. According to ACC/AHA angina guidelines 2002, there are three different classes of available to treat angina2. Class I drugs show evidence that they are useful and effective which include ASA, JNC VII HTN management, Smoking cessation (LDL>130), DM management, exercise, lipid lowering and weight reduction. Class II drugs have conflicting evidence of usefulness of which class IIa is in favor of usefulness and class IIb is in less favor of usefulness. Classs IIa include lipid lowering CAD (LDL 100-129), non HDL lowering in CAD (Trig >200, non-HDL