Mr. Johnson, a 54-year-old man began having chest pain 1

Mr. Johnson, a 54-year-old man began having chest pain 1 hour after his lunch break while he was at work. He described the pain as a “grabbing pressure” located midsternal. He rated the pain at “about a 4” on a scale of 1-10. He stated that the pain radiated down his left arm and through to his back. He was transported to the Emergency Department (ED) by ambulance. On admission, Mr. Johnson was pale, diaphoretic, and complained of shortness of breath. He denied nausea or vomiting. In the ED, unstable angina was diagnosed, and tests were ordered to rule out an acute myocardial infarction. He had experienced chest pain for 1 hour upon arrival in the ED at 8:13 PM. Mr. Johnson reports no previous episodes of chest pain or pressure. However, he admits he has had some “funny feelings” in his chest and has felt very tired lately but attributed it to a very stressful job. He has smoked two packs of cigarettes daily for 25 years. His mother died of Alzheimer’s disease and his father died of cancer. His paternal grandfather died of an MI, but there is no other family history of heart disease. 1.) What clinical data supports the diagnosis of angina? (1 point) Mr. Johnson is experiencing midsternal pain that he describes as a “grabbing pressure” that radiates down his left arm to his back. This pain description is consistent with classic angina. Mr. Johnson also appeared pale, diaphoretic and short of breath upon arrival at the ED. The length of Mr. Johnson’s chest pain lasted an hour which is consistent with his diagnosis of unstable angina since regular angina will resolve itself after a few minutes. 2.) What are Mr. Johnson’s risk factors? (1 point) Mr. Johnson’s risk factors include his stressful work environment, tobacco use, age, weight, and family history of MI. 3.) How do these risk factors contribute to and relate to his disease process? (1 point) Excessive stress over long periods raises cortisol levels which can lead to increased blood pressure, cholesterol, and triglycerides which are common risk factors for the development of angina (Tayrien, 2024, p. 1). Tobacco use causes blood vessels to thicken and constrict which increases blood pressure and makes it more difficult for the vessels to expand and contract (HeartFoundation, 2024, p. 1). Men over the age of 45 are more at risk for heart disease because as a person ages, their arteries harden making them not as flexible as they used to be (Forman, 2022, p. 1). Excess weight contributes to the risk for angina because the heart has to work much harder to supply blood to the body (PennMedicine, 2022, p. 1). A family history of MI means Mr. Johnson could have inherited various genes that put him at risk for developing heart disease. Assessment and diagnostic data on admission: BP 165/90 mm Hg, HR 92/min and regular, Respirations 32/min, Temp 98.50 F, SaO2 95% on 4L, Height 173 cm, weight 104 kg. The 12 lead EKG showed sinus rhythm with frequent PVCs, 3-4 beat runs of ventricular tachycardia and ST segment elevation. The chest x-ray revealed slight cardiomegaly and mild congestive heart failure. The echocardiogram findings revealed normal heart structures, ejection fraction (EF) of 25-30%, and mild mitral valve regurgitation. Cardiac enzymes were as follows at admission and on day 1: Admission 1:45pm Admission 9:45pm Day 1 5:45am Brain natriuretic peptide (BNP) (<100pg/mL) 565pg/mL 166pg/mL Troponin I (< 0.03ng/mL) 3.5 ng/mL >50 >50 4.) What do Mr. Johnson’s labs and diagnostic studies measure? (1 point) Mr. Johnson’s labs and diagnostic studies provide critical insights into his cardiac health. The BNP ( B type Natriuretic peptide) levels are used to evaluate heart failure, elevated BNP levels at admission suggest significant heart stress or failure, while a decrease over time (day 1 level decreased significantly from admission level) indicates potential improvement in heart function. On the other hand, troponin levels measure myocardial injury, elevated troponin at admission and a sharp increase on day 1 points to worsening damage to the heart muscle, possibly due to a myocardial infarction or severe ischemia. Together these markers help in assessing the severity of heart failure and myocardial injury, guiding treatment strategies, and monitoring the patient’s response to therapy (American College of Cardiology, n.d.). 5.) How do Mr. Johnson’s diagnostic findings relate to his disease process? (1 point) 6.) What should a normal ejection fraction be? (1 point) A normal ejection fraction would typically range for 55%-70%. Ejection fraction is a measure of the percentage of blood that the left ventricle pumps out with each heartbeat. Values below this range may indicate heart function issues (Cleveland Clinic, n.d.). 7.) What does his ejection fraction of 30% mean clinically? (1 point) An ejection fraction of 30% indicates that the heart left ventricle is pumping out only 30% of the blood it contains with each heartbeat. Normally the ejection fraction should be between 55%-70%. A EF of 30% suggests that the heart is not pumping effectively, which can be a sign of heart failure or other cardiac conditions. As the percentage falls, it tells the doctor that the heart failure is getting worse. In general, if the EF falls below 30%, it’s relatively severe. A reading of 20% or below is very severe heart failure. This reduced EF can lead to symptoms such as fatigue, shortness of breath, and fluid retention (WebMD, n.d.). 8.) How does his mitral valve regurgitation affect EF? (1 point) In the ED, Mr. Johnson’s chest pain was unrelieved after three sublingual nitroglycerin tablets. Morphine sulfate 5mg IVP was administered, resulting in a small decrease in pain. Aspirin 324mg was also given. After evaluation of the initial laboratory results, presenting symptoms, and the EKG, the diagnosis was an extensive anterior MI. Mr. Johnson was taken immediately to the cardiac catheterization laboratory for emergency angioplasty. The angiogram showed 90% blockage of the left anterior descending (LAD) artery. An emergency percutaneous transluminal coronary angioplasty (PTCA) was performed, but the artery continued to re-occlude, so a stent was placed. While the PTCA was being performed, Mr. Johnson became hypotensive, tachycardic, pale, cool, and diaphoretic. He complained of having shortness of breath, was restless, and rales were auscultated throughout all lung fields, and he was found to have jugular vein distention (JVD). A CXR showed pulmonary edema. A dobutamine drip was started at 6 mcg/kg/min. Abciximab (Reopro) bolus of 0.25mg/kg was given followed by an infusion at 0.125 mg/kg for 12 hours. He was also given 40 mg furosemide IVP and a nitroglycerin drip was started. A pulmonary artery (Swan-Ganz) catheter was placed. An intra-aortic balloon pump (IABP) was inserted in the right groin. 9.) What functionality of the heart can be affected by cardiogenic shock? (1 point) 10.) What is the pathophysiology of cardiogenic shock following an acute anterior MI? (1 point) 11.) What symptoms did Mr. Johnson exhibit to support the diagnosis of cardiogenic shock? (1 point) 12.) Calculate how many mL/hr you would program the IV pump for Mr. Johnson’s Dobutamine drip if the concentration was 500mg/250ml. (show your calculation) (1 point) Dobutamine Drip: 6ug/kg/min Weight: 104kg mLhr = 250 mL500 mgx 1mg1000 mcgx 6mcgkg/minx 60 min1 hrx 104kg1= 18.72 13.) What are the rationales for the six pharmacological agents that Mr. Johnson received? (1 point) Morphine: Mr. Johnson received Morphine to help with pain and anxiety from his STEMI occuring (this resulted in a small decrease in pain) Aspirin: Mr. Johnson received aspirin to help inhibit platelet aggregation as this plays an important role in the formation of blood clots. Aspirin helps prevent clot formation and reduce the risk of any further heart damage. Nitroglycerin: Mr. Johson received Nitroglycerin because it is a vasodilator. This helps open the blood vessels improving blood flow to the heart. Dobutamine: Abciximab: Furosemide: 14.) Explain the rationales for both the Swan-Ganz catheter and IABP and how they assist in Mr. Johnson’s plan of care. (1 point) During Mr. Johnson’s stay in the Cardiovascular Unit, he showed significant signs of improvement. On the morning of his second hospital day, Mr. Johnson had unlabored respirations and his vital signs were as follows: BP 100/60 (73), HR 105, CO 5 L/min, CI 2.2 L/min, respirations 20. The IABP settings were reduced to 2:1, the dobutamine drip was decreased and the nitroglycerine drip was discontinued. By the morning of the fifth day, all vasoactive drips were discontinued and hemodynamic values were within normal range. Preparation for transfer to the cardiovascular step-down floor was given. Mr. Johnson continued to improve and was discharged home on day 7.

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