Case Study 5—Coronary Artery Disease
It is midmorning on the cardiac unit where you work, and you are getting a new patient. G.P., a 60- year-old retired businessman, 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 and a 5-year history of angina pectoris. During the past week he has had more frequent episodes of midchest discomfort. The chest pain has awakened him from sleep but does respond to NTG, which he has taken sublingually about 8 to 10 times over the past week. During the week he has also experienced increased fatigue. He states, “I just feel crappy all the time anymore.” A cardiac catheterization done several years ago revealed 50% occlusion of the right coronary artery (RCA) and 50% occlusion of the left anterior descending (LAD) coronary artery. He tells you that both his mother and father had CAD. He is taking amlodipine, metoprolol, lipitor, and baby ASA qd.

Setting: Hospital, outpatient cardiac rehabilitation
Index Words: coronary artery disease (CAD), hypertension, angina, lifestyle modification, medications, laboratory values, assessment, risk factors, pacemaker

1. What other information are you going to ask about his episodes of chest pain? [k]

P Precipitating events What events or activities precipitated the pain (e.g., argument, exercise, resting)?
Q Quality of pain What does the pain feel like (e.g., pressure, dull, aching, tight, squeezing, heaviness)?
R Radiation of pain Where is the pain located? Does the pain radiate to other areas (e.g., back, neck, arms, jaw, shoulder, elbow)?
S Severity of pain On a scale of 0 to 10 with 0 indicating no pain and 10 being the most severe pain you could imagine, what number would you give the pain?
T Timing When did the pain begin?...

2. What are common sites for radiation of ischemic cardiac pain? [k]

Radiation of pain – The chest pain of cardiac ischemia often spreads to other areas of the upper body. This may include the neck, throat, lower jaw, teeth (feeling like a toothache), or the shoulders and arms. Sometimes, pain is felt in the wrists, fingers, or back (between the shoulder blades).

Note: Patients will tell you what you want to hear, so be careful how you ask your questions.

3. You know that G.P. has atherosclerosis of the coronary arteries but he has not told you about his risk factors. You need to know his risk factors for CAD in order to plan teaching for lifestyle modifications. What will you ask him about? [c]

4. Although he has been taking SL NTG for a long time, you want to be sure he is using it correctly. What information would you make sure he understands about the side effects, use, and storage of sublingual NTG? [c; an]

When you first admitted G.P., you placed him on telemetry and observed he was in A fib converting frequently to atrial flutter with a 4:1 block. His VS and all of his lab tests were within normal range, including troponin and CK levels; K was 4.7 mmol/L. He was converted with medications (quinidine and diltiazem) from A fib/atrial flutter to tachy/brady syndrome with long sinus pauses that caused lightheadedness and hypotension.

5. What risks does the new rhythm pose for G.P.? [c]

Because G.P.’s dysrhythmia is causing unacceptable symptoms, he is taken to surgery and a permanent DDI pacemaker is placed and set at a rate of 70/minute.

6. What does the code “DDI” mean? [k]

7. The pacemaker insertion surgery places G.P. at risk for several serious complications. List three potential problems that you will monitor for as you care for him. [c]

8. G.P. will need some education regarding his new pacemaker. What information will you give him before he leaves the hospital? [k,an, ap]

Note: Information about the Medic Alert emergency identification system can be obtained by calling 1-800-432-5378.

9. G.P.’s wife approaches you and anxiously inquires, “My neighbor saw this science fiction movie about this guy who got a pacemaker and then he couldn’t die. Is that for real?” How are you going to respond to her? [ap]

10. G.P. and his wife tell you they have heard that people with pacemakers can have their hearts stop because of theft and security sensors in stores and airports. Where can you help them find more information? [c]

After discharge, G.P. is referred to a cardiac prevention and rehabilitation center to start an exercise program. He will be exercise-tested, and an individualized exercise prescription will be developed for him based on the exercise test.

11. What information will be obtained from the graded exercise (stress) test (GXT), and what is included in an exercise prescription? [c]