Cardiovascular Case Study

Cardiovascular Case Study

Part One:

a Muslim American 68 year-old female, had been generally well until a recent vacation with her family.   She had been traveling by air from the Middle East to Europe when she complained of back pain.  Later she complained of chest pain that waxed and waned over the course of several hours. The pain returned but resolved by the flight’s completion.  Upon landing at the airport, the pain recurred. Patient also complained of excessive sweating and weakness.  Her daughter, recorded s blood pressure at 250/140 mmHg, and administered amlodipine (calcium channel blocker) and atenolol (PI-adrenergic antagonist .The  pain subsided for 1 hour, she was then rushed to the emergency room was presented with paperwork including those that would give her permission for evaluation procedures and tests, DNR, etc.

Upon arrival blood pressure was 156/77 mm Hg, pulse 58 beats per minute, respiratory rate 16 breaths per minute and oxygen saturation 89% while breathing ambient air she did not complain of nausea, vomiting, dyspnea (shortness of breath), or any heart palpitations, however she was quite lethargic due to pain intensity. Doctors performed an electrocardiogram (ECG), which revealed an elevated ST-segment.  A chest radiograph revealed a pulmonary edema. Doctors administered metroprolol (PI-adrenergic antagonist), heparin, (anticoagulant), and nitroglycerin (vasodilator). She was conscious at this time and was transferred to the cardiac unit for further evaluation.

Upon arrival to  Hospital,  she  reported an increase in pain intensity (8/9 out of 10, where 10 is the most severe).  Her blood pressure was once again elevated at 175/85 mm Hg, pulse 72 beats per minute, and respiratory rate 18 breaths per minute. Doctors noted that her jugular veins were slightly distended bilaterally.  Heart sounds were normal, Doctors obtained  medical history, which included treatment for hypertension and hyperlipidemia. Five years prior to this episode, doctors performed a cardiac stress test and cardiac computed tomography (CT), which were normal.  She is of Eastern European descent, lived in the Middle East and was not fluent in English. There was no history of smoking, alcohol abuse or illicit drug use.  An hour after arriving at the cardiac wing  she lapsed into a semiconscious state.

Doctors suspected that Amira was suffering from myocardial infarction, and they performed cardia catheterization to investigate the integrity of the coronary arteries.  The procedure revealed 20% stenosis in the left coronary artery, and complete occlusion of the middle portion of the left anterior descending (or interventricular) artery.  The right coronary artery as patent (open). As a precaution during the procedure, doctors placed a temporary pacemaker by inserting leads into the left anterior descending artery by first attempting to suction the clot from the vessel.  However, this was unsuccessful, and doctors performed a balloon angioplasty, which involved inflating the vessel to remove the clot. A metal stent was placed in the vessel following the angioplasty, and blood flow dramatically increased in the vessel immediately following the procedure.  An intraaortic balloon pump was placed in the aorta just adjacent o the left subclavian artery to inflate during diastole and deflate during systole, thereby increasing perfusion of the myocardium. Doctors increased the dosage of heparin and nitroglycerin following the procedure and continued to monitor Amira’s progress.

Part II:

Several hours later, doctors noted that Amira’s blood pH had dropped to 7.30.  Doctors performed a transthoracic echocardiogram which revealed a left ventricular ejection fraction of 35% reference, slightly dilated left ventricular cavity, akinesis of the left ventricular apex, and compensatory hyperkinesis of the left ventricular base.  There was no evidence of ventricular thrombus, yet there was evidence of pericardial effusion.  Doctors suspected that poor left ventricular ejection fraction was due to significant damage caused by myocardial infarction.

That evening, Amira’s chest pain returned, and an ECG revealed normal sinus rhythm yet an increased ST-segment elevation.  Doctors repeated the coronary angiography, which revealed that the left anterior descending artery remained patent.  However, doctors noted sluggish blood flow to the myocardium.  Doctors attempted to reduce afterload by administering angiotensin-converting enzyme (ACE) inhibitors.  Amira’s chest pain resolved.

On the third day, Amira’s hematocrit significantly decreased (24%) and she received 2 units of red blood cells.  At this time Amira experienced differing levels of consciousness.  By the fourth day, Amira’s condition appeared to stabilize and doctors removed the intraaortic balloon pump.  However, that afternoon, Amira’s mean arterial blood pressure dropped to 58 mm Hg.  By the evening Amira complained of mild dyspepsia (indigestion) and generally did not feel well.  Her pulse dropped to 55 beats per minute with increased ST-segment elevations.   Soon thereafter chest pains intensified and a pulse was undetectable.  Hospital personnel began cardiopulmonary resuscitation immediately.  Doctors intubated the trachea, administered epinephrine, normal saline, packed red blood cells, and atropine (muscarinic receptor antagonist).  A large pericardial effusion was detected, and doctors performed a pericardiocentesis, drawing – 750 ml of red, turbid fluid from the pericardium.  After 36 minutes of resuscitation efforts, Amira was declared dead, 90 hours after her admission to Carilion Hospital.

Following Amira’s death, doctors discussed the possible cause for a sudden onset of hypotension.  One hypothesis was the presence of a pulmonary embolus, however Amira had not prescribed heparin, making this explanation less likely.  In addition, Amira did not experience tachypnea (rapid breathing rate), as would be expected with a pulmonary embolus.  An alternate hypothesis was mechanical complication following myocardial infarction.  Mechanical complication may include a rupture of the heart wall or even rupture of the papillary muscle.  An echocardiogram taken during Amira’s hospital stay did suggest that there was a large pericardial effusion present, supporting the mechanical complication theory.  An autopsy revealed near-occlusive atherosclerosis of the left main, left anterior descending and circumflex arteries and a rupture in the anterior wall of the left ventricle.  This type of rupture occurs in 1-4% of myocardial infarction cases.  Immediate surgical repair is required for survival, however prognosis in these cases is very poor.

Case Study: Grading Rubric

Name: ___________________________________              Group #: ___________

Content: Questions are addressed with appropriate detail and conceptual understanding.

_____ (5 pts.) Justify the administration of amlodipine and atenolol for Susan’s elevated blood pressure (250/140 mm Hg). Be sure to address specifically how these drugs impact heart rate and blood pressure.

_____ (5 pts.) Predict the physiological consequences of Susan’s ECG results, namely an elevated ST-segment. Be specific to describe normal electrical conduction through the heart and discuss how electrical conduction may differ in Susan’s heart.

_____ (5 pts.) Describe the physiological consequences of a blocked left anterior descending artery. Be sure to describe the purpose of coronary circulation and the potential consequences of significant occlusion of these vessels.

_____ (5 pts.) Justify the administration of heparin and nitroglycerin following Amira’s cardiac catheterization procedure. Be sure to describe how heparin and nitroglycerin may impact blood flow within Amira’s coronary arteries.

_____ (5 pts.). Be sure to discuss specifically how ACE Describe how administering ACE inhibitors may reduce afterload inhibitors impact total peripheral resistance and mean arterial blood pressure.

_____ (5 pts.) Predict Amira’s hemoglobin levels following a significant decrease in hematocrit (24.5%). Discuss how administering 2 units of red blood cells may impact both hemoglobin and hematocrit levels, and discuss the physiological impact of this transfusion.

_____ (5 pts.) Justify the administration of epinephrine and atropine during Amira’s resuscitation attempt. Be sure to indicate the specific targets of each drug and their physiological effects.

____ (5 pts.) Describe how rupturing a ventricular wall or papillary muscle could lead to sudden hypotension. Be sure to describe blood flow through the heart, and discuss how these mechanical disruptions may impact stroke volume, cardiac output, and blood pressure.

____ (5 pts.) Which sociological theory/approach has the greatest appeal to you for the case study? Please share at least two examples from the case study to support your particular view.

____ (5 pts.)Foucault’s “gaze” is of special interest when examining this case study. Describe how you see the “gaze” being used.

_____ (Total: 50 points)

Grammar & Flow:

_____ (2 pts.) Spelling is technical, including word choice (e.g. their v. they’re) and plurality (e.g. use of plural instead of singular).

_____ (2 pts.) The basics of grammar are upheld, with no more than 3 occurrences of errors.

_____ (2 pts) Report is structured in paragraphs, one paragraph per idea, with logical flow from one thought to the next and the report is adequate length.

_____ (2 pts.) The report is well written, concise, and easy to read.

_____ (Total: 8 points)

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