CASE STUDY 1

Name:
CASE STUDY 2

Coronary Artery Disease (Case Study)

The patient Mrs. Emma is an 66-year-old woman. She arrived at the emergency room and complains of

chest pain, tightness, heaviness, and pressure in the chest behind the chest bone, fatigues weakness and

shortness of breath last week. Her vital sign were measured by the nurse. The blood pressure was higher than

normal 175/100 mmHg and pulse rate was also higher than normal 85 beats per minute. Her body weight was

greater than the recommnded BMI. The physical examination reveals the left upper limb swelling. The lung,

and abdominal examinations were normal. On asking about the severity of pain, she reported that the pain

radiates to her left arm. She was referred to a cardiologist. The cardiologist ordered her laboratory tests. The

laboratory tests indicate hyperglycemia, hypercholesteremia, higher LDL level, and low HDL level.

Angiography revealed 70% blockage of the right coronary artery and circumflex artery.

Mrs. Emma was admitted to the hospital and was suggested for the angioplasty. The patient

underwent the angioplasty. The angioplasty for the occluded right coronary artery and the stent placement in

the circumflex artery was successful. Mrs.Emma was discharged with the instruction to followup with the

physician.

Social History

Mrs. Emma Stone is a habitual drinker. She consumes a large amount of alcohol on daily basis. She is a

smoker also. She lives alone after the death of her husband in a suburban area. She is elderly with few friends.

The two people who visits her are her brother and sisters. Her three children usually stay away for hometown

due to work and study. She reported that last time she went for a walk almost a fortnight passed. She tries to

cook food at home but mostly consumes readily to eat food as she is not well, and has no one to cook for her.
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She remains at home and watches TV. She was brought to the hospital by her neighbors after she called them

and ask for help as she was not feeling well.

Past Medical History

The patient electronic health records showed that she has a past history of diabetes, obesity, hypertension,

asthma, depression, and moderate alcoholic hepatitis. She has been taking metformin, glibenclamide for

diabetes, Beta-1 selective blockers atenolol for hypertension, for asthma nebivolol, Selective serotonin reuptake

inhibitors escitalopram for depression and pentoxifylline for alcoholic hepatitis.

Surgery history

The patient electronic health records showed that she had a cesarean section three times in her life, during

the birth of her three kids. In addition to the c-section, she also had cholecystectomy for the removal of

gallstones. Some years back she had appendectomy for appendicitis.

Family history

She belongs to the Hispanic black family. Her husband was a salesman at a nearby store. Her husband

was a heavy smoker with COPD and died of lung cancer at the age of 62. She had three children. One daughter

and two sons, who remained out of home for the study and work. She has a family history of diabetes and

hypertension. Her mother passed because of a heart attack at the age of 75 . Her sister went angioplasty a year

ago. She also had a brother, who has diabetes and hypertension. As a Hispanic black family and low

socioeconomic status, her access to the health care system is restricted. Previously she was helped by her

brother financially for cholecystectomy.

Health Maintenance
CASE STUDY 4

Mrs.Emma is a lonely woman. She lives alone at this advanced age and has nobody to take care of her.

She is fatigued and weak physically. She likes to cook but is not able to because of weakness, dizziness she

mostly felt. She has developed depression due to loneliness and fewer visitors. She consumes alcohol and

smokes, which has worsened her asthma and alcoholic liver disease. She also has diabetes and hypertension.

She doesn’t consume healthy meals, and this has made her cholesterol, glycemic index worsen. Due to

depression, she is not able to sleep properly and this has increased her fatigue and weakness the next morning.

She is too older to cook for herself is this disease profile. There is no caretaker for her.

Current Medication

After angiography, she was discharged with the followup. Her current medication regimen was aspirin.

The use of aspirin prevents clot formation, by inhibiting the Thromboxane A2 and prostacyclin, thereby

inhibiting the platelet aggregation.HMG coenzyme A reductase inhibitors inhibit the HMG coenzyme A

reductase inhibits the synthesis the cholesterol. Ranolazine along with the nitroglycerine is prescribed to

alleviate the chest pain and meets the oxygen demand of the heart.

Epidemiology of the disease

Cardiovascular diseases are the leading cause of death around the world. Although the mortality due to the

coronary heart diseases has been reduced in the past few years, still it is the leading causes of death in

individuals more than 35 years of age ( Gomar et al, 2016). According to the Danish population data study from

1977 to 2011, about 5654 individuals were diagnosed with CAD, without follow-up ( Ben, 2012).

Rana et al studied the prevalence of coronary artery disease in diabetes and non-diabetes patients and concluded

that CAD was observed more in DM patients than those without DM. Rudisch & Nemeroff studied the co-

morbidity of depression and CAD, and find out that 17% to 27% of patients with CAD have depression also.

( Rudisch & Nemeroff, 2003).According to data by National Heart, Lung and Blood Institute Survey study,
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about 15.4 million Americans at the age of 20 have CAD. The prevalence increases with increasing age in both

men and women. ( Mack & Gopal, 2016).

Pathophysiology of disease

The function of the coronary artery is to supply blood to the heart. The heart needs oxygen-rich blood

for proper functioning. The oxygen-depleted blood must be carried away. Also, oxygen-depleted blood must be

carried away. The coronary arteries wrap around the outside of the heart. Since the coronary arteries supply

blood to the heart muscle, coronary artery disease compromise the blood supply to the heart and reduce the

oxygen and nutrient supply to the heart. In some cases, it leads to death due to the heart attack Atherosclerosis

(a buildup of plaque in the inner lining of an artery causing it to narrow or become blocked) is the most

common cause of heart disease. Platelets aggregate and cause intravascular occlusion that reduces myocardium

oxygen supply. Platelets attached to the endothelium and aggregates resulting in plaque formation. (Hall, 2016).

The mechanism behind the pathophysiology of CAD is the formation of atherosclerotic plaques, which involves

oxidative stress, endothelial dysfunction, immunological and inflammatory factors. Endothelial damage in the

CAD is caused by oxidative stress. The oxidative modification of lipoprotein is involved in the pathophysiology

of CAD. This promotes the incorporation of cholesterol in the atherosclerotic plaque. The endothelium-derived

relaxation by the production of the NO is lost in atherosclerosis. ( Torress et al, 2013).Paraoxonases are the

three enzymes that involve in antioxidation system. The alteration in these enzymes is associated with oxidative

stress. The paraoxonases are involved in the pathogenesis of coronary artery disease. (Abello et al, 2014).

Expected Findings

The patient should change her sedentary lifestyle. I can suggest adult day care to get her out, active and

interacting with others. She should have regular visitors to treat her depression. As literature has proved that

there is a comorbidity of the depression and coronary artery disease.Mrs.Emma stone should join some physical
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activity club, where she can make some friends and physical activity will also reduce her hypercholestermia and

decrease the incidence of further plaque formation, which can occlude the artery. Finally, I think she needs a

caretaker who can help her with cooking so that she consume good healthy food.Meals on the wheel can be an

option for her,if she remain hoomebound.

Pharmacological Treatment

There is two types of medications used in coronary artery disease patients. Antiplatelets to prevent blood

clots and statin which protect blood vessels. Beta blockers are also used to reduce the workload of the heart in

patients. Aspirin (Acetylsalicylic acid ) and clopidogrel are used in CAD. Statin is the drug that lowers the level

of cholesterol. Statins also have a protective effect on the blood vessels. Beta blockers act on the beta2 receptors

on the heart and reduce the cardiac output and heart rate. eptifibatide & ticlopidine are also used. Bile acid

sequestrants cholestyramine, colesevelam hydrochloride, colestipol hydrochloride, and fibrates fenofibrate are also used in

CAD. ( Weber, 2018)

References

Abello., D., Sancho., E., Camps., J., & Joven., J.( 2014). Exploring the role of paraoxonases in the
pathogenesis of coronary artery disease: A Systematic Review, International Journal of Molecular Sciences,
15(11), 20997-21010; doi:10.3390/ijms151120997
Ben., M., Watts., G., Hansen., A., & Norteesgard., B.( 2012). Familial hypercholesterolemia in the Danish
general population: prevalence, coronary artery disease, and cholesterol-lowering medication, The Journal of
Clinical Endocrinology & Metabolism, 97(11), 3956–3964. doi: 10.1210/jc.2012-1563
Gomar., L., Quilis., C., Leischik., R., & Lucia., A.(2016). Epidemiology of coronary heart disease and acute
coronary syndrome, Annals of Translational Medicine, 4(13),256-265. https://doi.org/10.1210/jc.2012-1563
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Hall, J. E. 1. (2016). Guyton and Hall textbook of medical physiology (13th edition.). Philadelphia, PA: Elsevier

Harvey., R.(2018).Lippincott illustrated Review: Pharmacology, Philadelphia: Wolters Kluwer Health

Mollack., M., & Gopal., A.( 2016). Epidemiology, Traditional and Novel Risk Factors in Coronary Artery
Disease, Heart Failure Clinics,12(1),1-10.doi: doi: 10.1016/j.hfc.2015.08.002.
Torres., F., Gemma., D., Romero., E.,……Sendon., L.(2013). Obstructive sleep apnea and coronary artery
disease: from pathophysiology to clinical implications, Pulmonary Medicine,19-28.doi:
http://dx.doi.org/10.1155/2013/768064

Rana., J., Dunnings., A., Achchen., Stephen.,…….Min., K.(2012). Differences in prevalence, extent, severity,
and prognosis of Coronary artery disease among patients with and without diabetes undergoing coronary
computed tomography angiography, Diabetes Care,35(8),1787-1794. doi: https://doi.org/10.2337/dc11-2403
Rudisch., B., & Nemeroff., C.(2003). Epidemiology of comorbid coronary artery disease and depression,
Biological Psychiatry, 53(4), 227-240. doi: https://doi.org/10.1016/S0006-3223(03)00587-0