Cardiovascular Analysis

The Assignment overview
Case Study:
A 49-year-old female patient with hypertension, hyperlipidemia, and overweight status presents with a two-week history of intermittent, squeezing chest pain radiating to the left arm. The pain worsens with physical activity and cold temperatures and is relieved by rest. The patient also reports occasional shortness of breath with exertion. The chest pain began during skiing and builds up before coming on suddenly. The patient has a stressful job, is a former smoker, and has a family history of heart disease. They are on hydrochlorothiazide 12.5 mg for hypertension.

1. What are 5 possible conditions that may be considered in a differential diagnosis for the patient?
   Given the patient’s clinical presentation, including risk factors and symptoms, several conditions could be considered in a differential diagnosis:
2. Stable Angina: This is a classic presentation, where chest pain occurs with exertion or stress and is relieved by rest. The history of hypertension, hyperlipidemia, former smoking, and family history of heart disease increases the likelihood of coronary artery disease (CAD) causing stable angina.
3. Unstable Angina: While the pain is not constant, if there is a worsening pattern of chest pain (i.e., occurring more frequently, with less exertion, or at rest), unstable angina should be considered. This is a precursor to myocardial infarction and requires urgent evaluation.
4. Myocardial Ischemia or Infarction (Heart Attack): Chest pain radiating to the arm, worsened by physical activity, and associated with shortness of breath could suggest myocardial ischemia. The intermittent nature of the pain could point to evolving ischemia or intermittent blockage of coronary vessels.
5. Aortic Dissection: Although less common, severe chest pain radiating to the back or arm can indicate an aortic dissection. Hypertension is a major risk factor. The pain can be abrupt and severe, mimicking angina or myocardial infarction.
6. Gastroesophageal Reflux Disease (GERD): While typically non-cardiac in origin, GERD can sometimes mimic cardiac chest pain. Chest pain related to eating or positional changes, relieved by antacids, might point to GERD rather than a cardiac cause.
   Given the patient’s cardiovascular risk factors, especially with a history of hypertension, smoking, and family history of heart disease, immediate cardiac should be ruled out urgently.

(from Rubric) Management Plan:

2. Use the expert diagnosis provided to create a pertinent, comprehensive, evidenced-based management plan.
   Answer- Due to the predictable, exertion-related nature of the chest pain, its relief with rest, and the presence of risk factors strongly suggest stable angina due to underlying coronary artery disease.
3. Address the following criteria in the plan: 1.) Diagnostic tests;
   To confirm the diagnosis of stable angina, assess the severity of coronary artery disease, and rule out other cardiac causes, the following tests are recommended:
   Diagnostic Tests
   • Electrocardiogram (ECG):
   o Order: Obtain a 12-lead resting ECG.
   o Rationale: To identify any ischemic changes, arrhythmias, or previous myocardial infarction indicators. Baseline ECG is essential for comparison with future tests.
   • Exercise Stress Test (Treadmill Test):
   o Order: Schedule an exercise ECG stress test.
   o Rationale: To assess the heart’s response to physical stress and identify exercise-induced ischemia. It helps determine the severity of the disease and guide treatment.
   • Echocardiogram:
   o Order: Perform a resting transthoracic echocardiogram.
   o Rationale: To evaluate cardiac structure and function, including ventricular function and valvular abnormalities.
   • Laboratory Tests:
   o Order:
    Complete blood count (CBC)
    Comprehensive metabolic panel (CMP)
    Lipid profile
    HbA1c
    Thyroid-stimulating hormone (TSH)
   o Rationale: To identify anemia, electrolyte imbalances, renal function, lipid abnormalities, diabetes mellitus, and thyroid disorders that may exacerbate angina.
   • Chest X-ray:
   o Order: Obtain a posterior-anterior and lateral chest radiograph.
   o Rationale: To assess heart size, pulmonary vasculature, and rule out other thoracic causes of chest pain.
4. Medications (write out a complete order, even for OTC meds);
   Medications
   • Nitroglycerin 0.4 mg sublingual tablets
   o Order: Take one tablet under the tongue at the onset of chest pain; may repeat every 5 minutes for a total of three doses. If pain persists after three doses, seek emergency medical attention.
   o Rationale: Provides rapid vasodilation, decreasing myocardial oxygen demand and relieving angina symptoms.
   • Metoprolol Tartrate 50 mg orally twice daily
   o Rationale: Beta-blockers reduce heart rate, blood pressure, and myocardial contractility, decreasing oxygen demand. They are first-line therapy for angina management.
   • Atorvastatin 40 mg orally once daily in the evening
   o Rationale: High-intensity statin therapy lowers LDL cholesterol, stabilizes atherosclerotic plaques, and reduces cardiovascular risk.
   • Continue Hydrochlorothiazide 12.5 mg orally once daily
   o Rationale: Ongoing management of hypertension.
   Suggested consults/referrals;
   • Cardiology Referral
   o Rationale: For specialized assessment, possible advanced imaging, and consideration of invasive interventions like angiography or revascularization.
   • Nutritionist/Dietitian
   o Rationale: To develop a weight loss plan addressing overweight status, dietary modifications for hypertension and hyperlipidemia.
   • Cardiac Rehabilitation Program
   o Rationale: To provide supervised exercise training, education on heart-healthy living, and support for lifestyle changes.
5. Patient education;
   • Medication Adherence:
   o Emphasize the importance of taking medications exactly as prescribed to manage symptoms and reduce risk of heart attack.
   • Lifestyle Modifications:
   o Diet:
    Adopt a heart-healthy diet rich in fruits, vegetables, whole grains, lean proteins, and low in saturated fats, trans fats, cholesterol, salt, and added sugars.
   o Weight Management:
    Aim for gradual weight loss to achieve a healthy body mass index (BMI).
   o Stress Management:
    Techniques such as mindfulness, deep-breathing exercises, yoga, or counseling to manage job-related stress.
   • Symptom Recognition:
   o Educate on recognizing signs of worsening angina or myocardial infarction, such as chest pain at rest, increased frequency or severity of pain, or new symptoms like nausea, dizziness, or profuse sweating.
   • Avoidance of Triggers:
   o Limit exposure to cold temperatures and avoid strenuous activity without proper warm-up.
6. Follow up, including time interval and specific symptoms to prompt a return visit sooner;

• Follow-Up Appointment:
  • Schedule a follow-up visit in 2 weeks to evaluate response to medications, review test results, and adjust treatment as necessary.
• Prompt Return if Symptoms Worsen:
  • Advise to seek immediate medical attention if chest pain:
  o Becomes more frequent or severe
  o Occurs at rest or with less exertion
  o Is not relieved by nitroglycerin
  o Is accompanied by symptoms like shortness of breath at rest, fainting, palpitations, or signs of stroke.