Introduction
The patients having serious heart conditions have to be treated based on pathophysiology and psychosocial aspects as it enables the healthcare professional to understand the patient history and understand the environmental factors affecting the patient (Banasik, 2018). This report discusses the condition of Betsy a 73 year old woman admitted in surgical ward complaining of nausea and shortness of breath. The report analyzes her health condition based on pathophysiology, pharmacology and psychosocial aspects and discusses the related heart conditions and impact of the medicines given to her.
Question 1
Betsy suffers from Chronic Obstructive Pulmonary Disease (COPD) and Coronary Heart Disease highlighting that she has respiratory disorder and her current condition where she is feeling short of breath and nauseous indicate the symptoms of the disease are increasing. COPD is chronic and progressive inflammatory condition that affects central and peripheral airways along with other impact to lung and pulmonary vasculature (Lumb & Biercamp, 2014) This needs to be addressed to avoid further complications as she has also had Coronary Artery Bypass Graft (CAGSs) earlier and her current symptoms can lead to serious consequences such as heart attack. As Betsy is feeling short of breath Electrocardiography (ECG) is essential to monitor if there are any abnormality or changes in the pathophysiology of the airway disease of the patient. ECG request was made by buddy nurse as Betsy has COPD and coronary heart disease. There is coexisting cardiac disease in patients who have COPD and when there are certain symptoms such as shortness of breath, ECG can help in diagnosing whether the underlying cause of breathing difficulty is not cardiac in nature (Larssen et al., 2016). The different respiratory disease are caused due to changes in heart, which ECG can detect, and it can help in updating or changing clinical decisions in patients with respiratory problems (Warnier et al., 2013). ECG in case of Betsy will help in better understanding the dominant pathophysiology of the airway issue that she was facing and to ensure there is not cardiac issue.
Question 2
2a.
Stable angina refers to a condition in an individual wherein he/she has brief episodes of pain, pressure, squeezing or tightness in chest and is mostly a symptom of coronary heart disease (Kaski, 2016). Stable angina is the result of imbalance between oxygen demand and myocardial blood supply (Henry, 2016). In case of Coronary Artery Disease, free radicals and different inflammatory mediators in atherosclerosis can damage collagen synthesis that is essential for repairing and managing fibrous cap and triggering degradation of the extracellular matrix macromolecules that continues to weaken the fibrous cap of plaque and increases the patient’s vulnerability to rupture, this leads to progression of stable angina to unstable angina the outcome of the same can be patient effected by Myocardial Infraction (MI) (Uppal et al., 2014). Unstable angina also known as acute coronary syndrome leads to unexpected chest pain and occurs mostly while resting . The main cause of unstable angina is the reduced flow of blood to heart muscles as the coronary arteries are narrowed due to atherosclerosis i.e. fatty buildups and can rupture, which leads to blood clotting and blocking blood flow to heart muscle (Henry, 2016). The symptoms of unstable angina include pain or discomfort while resting, sleeping or physical exertion, can get worse over time and rest or medicine do not help relieve it and the outcome can be heart attack if not addressed immediately (Henry, 2016). NSTEMI or non-ST segment elevation myocardial infraction refers to a type of heart attack and can be detected through ECG and the severity is detected by the GRACE score wherein the factors such as heart rate, systolic blood pressure, ST-segment deviation in the ECG, elevated cardiac marker are detected (Marfella et al., 2017).
The NSTEMI is diagnosed when a person has symptoms of unstable angina and through ECG it NSTEMI occurrence can be identified (Henry, 2016). In case of patients with NSTEMI and type 32 diabetes can lead to adverse cardiovascular outcomes as compared to one who do not have diabetes (Marfella et al., 2017). ST Elevation Acute Myocardial Infarction (STEMI) refers to the serious manifestation of coronary artery disease. It causes notable chest pain/discomfort due to STEMI segment elevations that can be observed on ECG and due to elevated troponin levels (Kaski, 2016). The progression of SETMI is that complete occlusions in artery are causes that leads to severe ischemia in myocardium coming though artery (Henry, 2016). The ischemia is transmural highlighting that it affects the entire layer of muscle causing increased risk of heart complications and can lead to death in case patients have diabetes (Birkner, Hudzik & Gasior, 2017). As Betsy has stable angina and her pain is reducing when GTN is administered hence she does not have any major threat related to any cardiac problem.
2b
Acute coronary Syndrome (ACS) is a range of clinical presentations mainly associated with rupture of atherosclerotic plaque in coronary artery that is followed by partial or complete thrombosis (Phalen & Aehlert, 2018). There are several risk factors that increases the risk of ACS in people. In case of Betsy, the two risk factors that can increase her risk of ACS are
- Hypertension
- Type 2 Diabetes
Hypertension is associated with increase in atherosclerosis and contributes to progression of myocardial infraction thereby increasing risk of ACS (Lumb & Biercamp, 2014). Type 2 diabetes also accelerates atherosclerosis due to insulin resistance that causes dyslipidemia and hyperglycemia reducing nitric oxide in blood vessel walls and making diabetes a risk factor for ACS (Birkner et al., 2017).
Question 3
Rhythm
A poor right ventricular function is indicated in abnormalities tachycardic rhythm in the ECG shown in Appendix 1. Tachycardic rhythm in the ECG shown in appendix is indicative of an existing COPD.
Rate
Rate appears to be normal and not elevated. An elevated rate of impulses might have indicated sinus tachycardia.
Presence and regularity of p waves
The p waves that appear in the ECG shown in Appendix 1 are tall, narrow and peaked at electrocardiographic leads II, III and aVF are indicative of p pulmonale. This is further indicative of an existing chronic obstructive pulmonary disease or COPD. The p waves amplitude appears to be greater than 2.5 mV in the interior leads, which is further indicative of a P pulmonale.
ST segment
There are slight ST segment depressions in in the inferior leads, which suggest prominent atrial repolarization abnormalities. This may further indicate an unstable angina.
Question 4
Acute coronary syndrome (ACS) refers to set of term for conditions that are caused by sudden blockage of blood supply to heart (Mirza, Taha & Khdir, 2018). It can lead to heart attack i.e. myocardial infraction when cell death damages or destroys tissue of heart (Mansour et al., 2017). The three of central findings that can potentially lead to diagnosis of ACS are identified through ECG and blood tests and cardiac perfusion scan. In ECG, the electrical activity in heart are tested wherein abnormal or irregular impulses are checked for that indicate poor heart function due to lack of oxygen supply to heart and electrical signal patterns also indicate location of blockage (Mirza, Taha & Khdir, 2018). This provides some information about chances of ACS in a patient. The blood test then helps in detecting enzymes in blood that cause cell death resulting in heart tissue damage and then cardiac perfusion scan helps in detecting whether heart is getting adequate blood and can check area of damage in case a heart attack as occurred (Mansour et al., 2017). Thus, the electrical activity, cell death and any damage caused to any area can help in diagnosing a patient with ACS.
Question 5
|
Generic Name
|
GTN
|
Diltiazem
|
Pravastatin
|
|
Drug Group
|
Nitrates or vasodilators
|
Calcium-channel blockers (PDR, 2019)
|
Statins (PDR, 2019)
|
|
Mechanism of action
|
Acts on vascular smooth muscles in order to produce arterial and venous vasodilation (NSW Government, 2014). It improves myocardial perfusion and results in reduction in work performed by heart and reduces demand of oxygen by heart
|
Relaxes smooth muscle in walls of arteries allowing them to open and enhance blood flow (PDR, 2019).
|
Acts as a lipoprotein-lowering drug and used to lower cholesterol and triglycerides in blood (PDR, 2019). It is associated with mild asymptomatic and self-limited serum aminotransferase elevations during therapy (PDR, 2019).
|
|
Complications/side effects
|
· Headache (NSW Government, 2014)
· Fainting and dizziness
(NSW Government, 2014)
|
· Weakness (PDR, 2019)
· Nausea(PDR, 2019)
|
· Headache(PDR, 2019)
· Nausea(PDR, 2019)
|
|
Nursing Considerations
|
Use the spray cautiously as Betsy is already feeling short of breath and can feel dizzy (NSW Government, 2014)
· Allow 10hours of GTN free period to avoid tolerance and maintain the effects
(NSW Government, 2014)
|
· Blood pressure and pulse to be monitored before, during and periodically when dosage is given (PDR, 2019)
· Not allow any physical activity after the medicine is taken (PDR, 2019)
|
· Cheek lipid profile (PDR, 2019)
· Check cholesterol level (PDR, 2019)
|
Question 6
Aspirin is considered to be a standard antiplatelet agent for prophylaxis influencing myocardial infraction and other thromboembolic events (Degrauwe et al., 2017). There are another set of antiplatelet agents called thienopyridines that include clopidogrel, ticlopidine and prasugrel, which inhibits adenosine diphosphate induced platelet aggregation irreversibly through P2Y12 receptor that is present on surface of platelets (Juneja, Gupta & Kausahl, 2013). Ticagrelor is a novel non-thienopyridine platelet P2Y12 receptor antagonist and is the first agent in new chemical class of cyclopentyl-triazolo-pyrimidines (Berger, 2013). Ticagrelor is found to be effective as compared to clopidogrel as it selectively blocks the platelet P2Y12 by interacting with binding site. Ticagrelor is associated with significant reductions in cardiovascular events and mortality as compared to clopidogrel (Degrauwe et al., 2017). Low-dose aspirin with ticagrelor helps in decreasing cardiovascular events in patients with ACS (Juneja et al., 2013). These combined drugs will help Betsy in increasing the blood and oxygen flow to heart and help in improving her breathing. It will also avoid any situations of blood clotting and increased stress on heart and avoid the risk of mild to serious heart attack.
Question 7
In early treatment of ACS, antiplatelet agents i.e. aspirin and P2y12 inhibitors, coronary revascularization and anticoagulants are widely used which improves the prognosis (Bonin et al., 2018). Morphine is widely recommended for patients with ACS for pain control. It is one of the potent analgesics and is competitive agonist of μ-receptors in central nervous systems and smooth muscle (Duarte et al., 2018). But the safety of Morphine in ACS patients is questioned as it is believed to delay and decrease efficacy of antiplatelet agents. The advantage of using morphine for ACS is that it is a potent opiod making it ideal analgesic having innate hemodynamic effects, which are beneficial for controlling myocardial infraction (Ghadban et al., 2018). It helps in decreasing blood pressure, heart rate and venous return and also influences the local histamine process and hence reduces myocardial oxygen demand (Bonin et al., 2018). But on the other hand morphine delays and reduces the release peak and efficacy of healthy patients taking oral antiplatelet agents for ACS and inhibits gastrointestinal absorption inducing vomiting in some cases (Duarte et al., 2018). But the newer antiplatelet agents that include ticagrelor and prasugrel are not affected by morphine due to their high potency (Ghadban et al., 2018). Some researchers have highlighted that though there is increased risk of recurrent MI but there is no increased risk of mortality (Duarte et al., 2018). Thus, morphine might not have a serious impact on patients but might not reduce the symptoms of Mi completely.
Question 8
Coronary artery disease (CAD) is found to cause major depressive disorder in patients. Several researches have highlighted the association of coronary artery disease with depression (Dhar & Barton, 2016). Biobehavioral mechanism is considered to be the underlying cause for relationship between depression and CAD (Qing & Kling, 2016). The poor lifestyle factors such as physical inactivity, smoking, hypertension, diabetes and insulin resistance lead to changes in platelet reactivity and dysregulated autonomic nervous system and hypothalamic pituitary adrenal axis (Dhar & Barton, 2016). This leads to alterations in immune responses and inflammation. Increased levels of platelet reactivity is associated with increased levels of depression (Qing & Kling, 2016). Betsy has increased risk of having depression due to CAD as there is reduced physical activity and increased platelet reactivity for which she is taking anti-platelet medications already. Besides this, Betsy has hypertension which further increases her mental stress and leads to depression. Researches have demonstrated that patients with hypertension, have reduce uptake of noradrenalin and activation of brain noradrenergic pathways that lead to depression. Betsy thus, has increased risk of depression (Dhar & Barton, 2016).
Conclusion
Betsy’s condition of feeling nauseous and short of breath required various tests and identification of other symptoms to administer the required medicines. ECG advised by buddy nurse was essential to rule out any cardiac problem. Her stable angina and response to GTN highlighted that she does not face any immediate threat or heart issue. The combination of Aspirin and Ticagrelor will help ease Betsy’s condition by reducing her symptoms through good blood flow. Due to her coronary heart disease Betsy does have increased risk of depression.
References
Banasik, J. (2018). Pathophysiology (6 th ed.), New York: Saunders.
Berger, J. (2013). Aspirin, clopidogrel, and ticagrelor in acute coronary syndromes. Am J Cardiol., 112(5), 737-745.
Birkner, K., Hudzik, B. & Gasior, M. (2017). The impact of type 2 diabetes mellitus on prognosis in patients with non-ST elevation myocardial infarction. Kardiochir Torakochirurgia Pol., 14(2), 127-132.
Bonin, M., Mewton, N., Roubille, F., Morel, O., Cayla, G.,Angoulvant, D., Elbaz, M., Claeys, M., Garcia-Dorado, D., Giraud, C., Rioufol, G.,Jossan, C., Ovize, M., Guerin, P. (2018). Effect and Safety of Morphine Use in Acute Anterior ST-Segment Elevation Myocardial Infarction. Journal of the American Heart Association, 1-10.
Degrauwe, S., Pilgrim, T., Aminian, A., Noble, S., Pascal, M. and Iglesias, J. (2017). Dual antiplatelet therapy for secondary prevention of coronary artery disease. Open Heart, 4, 1-16.
Dhar, A. & Barton, D. (2016). Depression and the Link with Cardiovascular Disease. Frontiers in Psychiatry, 7(33), 1-9.
Duarte, G., Nunes-Ferriera, A., Rodrigues, F., Pinto, F., Ferreira, J., Costa, J., Caldeira, D. (2018). Morphine in acute coronary syndrome: systematic review and meta-analysis. BMJ Open,9, 1-10.
Ghadban, R., Enezate1, T., Payne, J., Allaham, H., Halawa1, A., Fong, H., Abdullah, O., Aggarwal, K. (2018). The safety of morphine use in acute coronary syndrome: a meta-analysis. Heart Asia, 11(1).
Henry, T. (2016). Controversies in the Management of STEMI., New York: Elsevier.
Juneja, S., Gupta, K. & Kausahl, S. (2013). Ticagrelor: An emerging oral antiplatelet agent. J Pharmacol Pharmacother, 4(1), 78-80.
Kaski, J. (2016). Essentials in Stable Angina Pectoris. New York: Springer.
Larssen, M., Hodnesdal, C., Skjorten, I., Hilde, J., Steine, K., Liestol, K., Gjesdal, K. (2016). Mechanisms of ECG changes in chronic obstructive pulmonary disease. European Respiratory Journal, 4(1), 1-10.
Lumb, A. & Biercamp, C. (2014). Chronic obstructive pulmonary disease and anaesthesia. Continuing Education in Anaesthesia Critical Care & Pain, 14(1), 1–5.
Mansour H., Reda A., Mena M., Ghaleb R., Elkersh A. (2017). Pattern of risk factors and management strategies in patients with acute coronary syndrome, in different age groups and sex categories. Atherosclerosis Supp., 25, 7-8.
Marfella, R., Sardu, C., Calabrò, P., Siniscalchi, M., Minicucci, F., Signoriello, G., Balestrieri, M., Mauro, C., Rizzo, M., Paolisso, G. & Barbieri, M. (2018). Non-ST-elevation myocardial infarction outcomes in patients with type 2 diabetes with non-obstructive coronary artery stenosis: Effects of incretin treatment. Diabetes Obes Metab, 20(3), 723-729.
Mirza, A., Taha, A. & Khdir, B. (2018). Risk factors for acute coronary syndrome in patients below the age of 40 years. The Egyptian Heart Journal, 70(4), 233-235.
NSW Government. (2014). Glyceryl Trinitrate (GTN). Retrieved from
https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0020/306371/liverpoolGlyceryl_Trinitrate.pdf
Phalen, T. & Aehlert, B. (2018). The 12-Lead ECG in Acute Coronary Syndromes (4 th ed.). Missouri: Mosby/JEMS.
PDR. (2019). Pravastatin sodium - Drug Summary. Retrieved from
https://www.pdr.net/drug-summary/Pravachol-pravastatin-sodium-910
PDR. (2019). Diltiazem hydrochloride - Drug Summary. Retrieved from
https://www.pdr.net/drug-summary/Cardizem-diltiazem-hydrochloride-2077
Qing, W. & Kling, J. (2016). Depression and the Risk of Myocardial Infarction and Coronary Death: A Meta-Analysis of Prospective Cohort Studies. Medicine, 95(6).
Uppal, N., Uppal, V. & Uppal, . (2014). Progression of Coronary Artery Disease (CAD) from Stable Angina (SA) Towards Myocardial Infarction (MI): Role of Oxidative Stress. Journal of Clinical & Diagnostic Research, 8(2), 40-43.
Warnier, M., Rutten, F., Numans, M., Kors, J., Tan, H., DeBoer, A., Hoes, A. & DeBruin, M. (2013). Electrocardiographic Characteristics of Patients with Chronic Obstructive Pulmonary Disease. Journal of Chronic Obstructive Pulmonary Disease, 10, 62-71.
