Clinical Case
A 56-year-old male was brought to the hospital by ambulance. He had earlier complained of severe chest pain, which had started in the past 24 hours. He went into cardiac arrest on his way to the hospital. His son stated that the patient was a heavy smoker. Other signs and symptoms observed earlier include discomfort in the arms and legs, nausea and cold sweats, dizziness, and difficulty in breathing. Upon arrival to the hospital, first aid was performed in the emergency room.
Diagnosis Testing
There are several differential diagnoses in this case such as pulmonary thromboembolism, acute coronary syndrome (ACS), and aortic dissection. The risk factors for heart disease for this patient are smoking, gender, and age. In assessing chest pain, I utilize three basic parameters, which are the clinical examination (physical examination and clinical history), myocardial necrosis markers, and electrocardiogram (ECG). In this case, the fact that the patient is exhibiting prolonged chest pain raises high suspicion for coronary acute symptoms. However, other conditions such as mechanical pericarditis complications could be the cause of the pain.
Chest pain presentation is commonly attributed to heart disease (coronary acute syndrome). To rule out acute coronary syndrome, I ordered echocardiography to be performed for differential diagnosis. I use an electrocardiogram for identification because it is a noninvasive technique. Furthermore, this diagnostic test and procedure reveal whether the heart is damaged, and the degree of coronary disease in a person. My team of nurses conducted an electrocardiogram within the first ten minutes of the patient’s arrival.
My first step of the etiology examination, in this case, is to determine the presence and the characteristics of angina in patients. Angina is compression, a burning sensation, or breathing difficulty found in the pericardial area that radiates pain to the shoulders, neck, and left arm (Tillmann et al., 2017). I physically examined the patient with the help of an emergency nurse.
Results
There was no pleuritic pain and pain with local palpation, I rule out coronary disease. His blood pressure was 110/70 mmHg, and his heart rate was 90 bpm. There were heart systolic murmurs in the mitral border and the lower left sternal border, and the lung had not changed. The first electrocardiogram showed a 100 bpm heart rate and widespread continuing wall infarction in the anterior. The first ECG results, in this case, the echocardiography showed an ST-segment elevation in the anterior wall (V2-V6). Thus, I classified the patient’s condition under ST-elevation myocardial infarction (STEMI) criteria.
There was an urgent need to reverse cardiorespiratory arrest and bradycardia. Therefore, I administered acetylsalicylic acid orally and 5 mg metoprolol intravenously. Unfortunately, he developed peripheral hypoperfusion and hypotension after the medications, which caused continuous intravenous norepinephrine and heparin to be administered by the nurse. Thereafter, the patient was taken to the catheterization lab, coronary angiography was detected, occlusion was seen in the intraventricular branch, and his artery was completely occluded. I had to perform angioplasty using a stent implant within the anterior interventricular artery to restore distal flow. The left ventricular function was not resumed immediately after reperfusion. However, it took almost 72 hours for the patient to stabilize.
Treatment
I prescribed Clopidogrel 300 mcg, C Atorvastatin 80 mg, Ramipril 2.5 mg, and GTN 500 mcg to the patient. These are appropriate medications for myocardial infarction, my preference for these drugs is guided by the fact that Aspirin, Atenolol, Clopidogrel, and Atorvastatin have been found to relieve chest pains significantly. In addition, the function of ACE inhibitors is to improve intraventricular modeling after an attack. Morphine and GTN are good for alleviating pain and relieving other symptoms exhibited and they do not have a prognostic effect. Therefore, the nurses can administer them in parallel. During this treatment, I ensure that the oxygen level in the patient is at a saturation level of more than 95%.
An ST elevation in V2-V6 confirmed the presence of anterolateral STEMI, which is an indication of occlusion in the left anterior descending coronary artery (LAD). My treatment strategy, in this case, is to offer optimal management for this patient. Thus, instead of undertaking reperfusion therapy and percutaneous intervention followed by thrombolysis, I have opted for coronary angiography. The patient will be monitored by the nurses for the next three days. Upon discharge, then he will be taking a dose of Clopidogrel (300 mg) and daily maintenance of 75 mg.
The patient will need to attend cardiac rehabilitation for one month after discharge. This program helps in bridging the gap between patients at home and hospitals, it starts immediately after the patient is admitted. The rehabilitation team consists of healthcare professionals, whose role is to advise the patient appropriately on heart disease risk factors. The patient is also educated to embrace healthy lifestyles to stop future heart problems. Issues to be addressed for this patient include diet, exercise, smoking cessation, and pharmacotherapy. Additionally, information on medications recommended is given to emphasize the need for adherence. I am among the facilitators in the program, therefore, I will also monitor my patient as he attends the therapy.
Reference
Tillmann, T., Vaucher, J., Okbay, A., Pikhart, H., Peasey, A., Kubinova, R., & Fischer, K. (2017). Education and coronary heart disease: Mendelian randomisation study. British Medical Journal, 358, j3542.