Case 005: Stable Ischemic Heart Disease

PATIENT PRESENTATION

Chief Complaint

“I started to notice pain in my chest and difficulty breathing while playing with my grandkids at the park. I must sit down and rest for the pain and shortness of breath to go away”

History of Present Illness

62-year-old Hispanic female who, for the past few weeks, has been experiencing chest pain and shortness of breath while playing with her grandchildren. This sensation is new to her occurring with physical activity and exertion. Her symptoms improve after she sits down to rest.

Link to EMR

Student Work-Up

TARGETED QUESTIONS

1. What symptoms of chronic stable angina does the patient have?

   Hint: See Clinical Presentation and Diagnosis in PPP

2. What are the patient’s risk factors for SIHD?

   Hint: See Pathophysiology in PPP; See table 8-2

3. What is your assessment of the patient’s current hypertension and diabetes regimen?

   Hint: See Treatment; See hypertension chapter 5 and diabetes chapter 44 in PPP

4. The patient undergoes a scheduled coronary angiogram showing an 80% occlusion in the left anterior descending coronary artery and a 60% occlusion in the right coronary artery. Percutaneous coronary intervention (PCI) is performed, and a drug-eluting stent (DES) is placed in both arteries. Which antiplatelet therapy do you recommend for this patient and for what duration?

   Hint: See Treatment in PPP

5. What therapy do you recommend to manage this patient’s current symptoms of angina?

   Hint: See Treatment in PPP

FOLLOW-UP

The patient returns to her primary care physician 3 months later as a general follow-up visit for assessment and labs. What additional medication changes would you consider to manage this patient’s SIHD and what lifestyle modifications would you recommend for this patient?

Hint: See Treatment in PPP

CASE SUMMARY

Global Perspective

This patient presents with symptoms consistent with SIHD. The patient is now diagnosed with SIHD. Her history, risk factors, and suboptimal management of concomitant chronic conditions is what likely contributed to the establishment of her atherosclerotic cardiovascular disease. To improve her outcomes, all aspects of her SIHD risk factors need to be addressed which include proper management of SIHD according to national guidelines, aggressive management of modifiable risk factors and comorbid conditions, and lifestyle modifications to delay progression of disease, prevent adverse outcomes, and improve patient quality of life.

Key References