The patient Mrs. Emma Stone is an66-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 on 10th Feb 2019.Her vital sign was 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 BMI.The physical examination reveals the left upper limb swelling.The lung,abdominal examination was normal. On asking about the severity of pain,she told that the pain radiates to her left arm.She was referred to a cardiologist. The cardiologist prescribed her laboratory tests.All 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.
Miss Emma Stone was admitted to the hospital on 12th February 2019 and was suggested for the angioplasty.The patient was subjected to the angioplasty.The angioplasty for the occluded right coronary artery and the stent placement in the circumflex artery went successful.
Mrs.Emma stone was discharged with a followup.
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 an old lady with not many friends.The two visitors to her in 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.Shetries 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.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.
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.
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.Her sister went angioplastya 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 always restricted. Previously she was helped by her brother financially for cholecystectomy.
Mrs.Emma stone is a lonely woman.She lives alone at this old 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.
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 Areductase 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, 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 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).
The patient should change her sedentary lifestyle.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 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.
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, colestipolhydrochloride, and fibrates fenofibrate are also used in CAD.( Lippincott, 2018)
Abello.,D., Sancho.,E.,Camps.,J., & Joven.,J.( 2014).Exploring the role of paraoxonases in the pathogenesis of coronary artery disease: A Systematic Review,
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.
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
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.
Rudisch., B., & Nemeroff., C.(2003).Epidemiology of comorbid coronary artery disease and depression, Biological Psychiatry, 53(4), 227-240.
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