Multi-Vessel Coronary Artery Stenosis: A Case Study Report



77001371600540005431155Multi-Vessel Coronary Artery Stenosis: A Case Study ReportPriority nutrition care distance dietetic internshipAleysia Kroptavich7900035000Multi-Vessel Coronary Artery Stenosis: A Case Study ReportPriority nutrition care distance dietetic internshipAleysia Kroptavichright23002311402018760098002018Introduction:The patient I chose to study was diagnosed with Multi-Vessel Coronary Artery Stenosis. I chose this patient because she was unique in that she presented to the hospital for an evaluation of the shortness of breath she was experiencing for several days prior. Shortness of breath (SOB) is a causative symptom for many different diagnoses, so it was interesting to see what was causing hers. I met the patient when nutrition services received a consult from the physician to do CHF diet teaching as well as recommend weight loss with her. It was a benefit to see her and learn about her case in the inpatient setting. She was admitted to the hospital due to experiencing dyspnea with exertion for several days prior. I respect this patient because she was her own best advocate in terms of making sure that she was being taken care of and receiving adequate nutrition. She remained positive in spite of her diagnosis and that made me really enjoy working with her. I was able to converse with the patient about her diet, in and out of the hospital, and she was very approachable to the education I provided her. The patient is a Type II diabetic with no complications, but since interning at Wayne Memorial Hospital I have become incredibly interested in the importance of nutrition in Diabetes, in which I may study furthermore. This is just another reason why I chose this patient for my case study.By choosing this patient, I hope to educate myself about her multiple diagnoses and its conditions as well as treatments. Many patients I have had to assess had a history of a shortness of breath, but never anything like her case. There is much to learn about the complications within the heart and its proper treatments, because it encompasses quite a large variety of diseases. Discussion of Disease:Multi-vessel Coronary Artery Stenosis, also called coronary artery disease (CAD), develops due to a buildup of cholesterol and other fatty substances in the blood vessels that supply to the heart. This means that there are more than 2 or 3 epicardial coronary arteries suffering from a severe atherosclerosis. Multivessel disease often brings left ventricular dysfunction, and cardiovascular risk. In general, the prognosis of coronary artery disease is related to the number of affected vessels (one-, two- or three vessel coronary artery disease) and the degree of dysfunction of the left ventricle (the heart chamber that pumps out blood to the rest of the body other than the lungs). To say exactly when civilization first became aware of CAD is difficult. However, it is known that Leonardo Da Vinci (1452-1519) investigated coronary arteries (1). Approximately 1 of every 13 Americans aged 18 years and older has CAD. It is the leading cause of death for people of most racial and ethnic groups in the United States. In the United States, CAD is most common among Hispanic Americans and least common among Asian Americans, Pacific Islanders, American Indians, and Alaska Natives. Coronary artery disease develops gradually, so it is also typically a disease of elders; in fact, the strongest risk factor for CAD is age. Although the disease may become clinically apparent by age 40, people 65 years of age and older account for approximately 85% of deaths from CAD (4). The symptoms of coronary artery disease will depend on the severity of the disease. Some persons with CAD have no symptoms, some have episodes of mild chest pain or angina, and some have more severe chest pain (angina). Though, when symptoms of coronary artery disease are present, each person may experience them differently. Symptoms of coronary artery disease may include heaviness, tightness, pressure, and/or pain in the chest - behind the breastbone, pain radiating in the arms, shoulders, jaw, neck, and/or back, weakness/fatigue, and/or shortness of breath (4). There are many ways to treat CAD, one being with medication. Several types of medications may be used to treat coronary artery disease, depending on the persons health profile and symptoms, including: Cholesterol-lowering medications. Statins and other medications are often very effective in lowering blood levels of LDL (the “bad" cholesterol). Other medications may be used to raise levels of HDL (the "good" cholesterol). Together, these two steps can slow or stop plaque build-up in the arteries. Beta blockers. These medications slow the heart rate and reduce the heart's demand for oxygen. A beta blocker may be prescribed by a doctor if a patient has high blood pressure or angina, or have had a heart attack. Aspirin. By warding off blood clots, aspirin can help save lives during a heart attack. Angiotensin-converting-enzyme (ACE) inhibitors. These medications are used to treat high blood pressure. In addition, if one had a heart attack, taking an ACE inhibitor can prevent another heart attack. Calcium-channel blockers. These medications relax blood vessels, which reduces high blood pressure and lightens the heart's workload as it pumps blood throughout the body. Some types of calcium-channel blockers also slow the heart rate. A lighter workload means the heart muscle needs less oxygen-rich blood, and reduces the likelihood that one will develop chest pain. And lastly, Nitroglycerin. Nitroglycerin and other forms of nitrates cause the arteries and veins to relax. This lightens the heart's workload by reducing the pressure the heart has to pump against (5).Another way to treat CAD is with surgery. Some people with coronary artery disease have widespread plaque in several arteries, or a severe narrowing in the main artery that transports blood from the aorta to the heart. In this situation, the doctor may recommend that it is safer and more effective for their patient to have coronary artery bypass graft (CABG) surgery, rather than angioplasty and stenting (conducted if a blockage or plaque is severe enough). During bypass surgery, arteries or veins are taken from other parts of the body, such as the chest and the legs, and sewn onto the diseased arteries in the heart, above and below the obstructive plaque. The new arteries and veins serve to detour blood flow around the plaque, keeping blood flowing to the heart muscle (5). Several things increase ones risk for coronary artery disease, including hypertension, cigarette smoking, diabetes, obesity, being male, a family history of the disease and a high cholesterol level. Although one can't change all of the things that increase the risk of coronary artery disease, lowering cholesterol level can be done by making diet changes and quitting smoking. When trying to lower LDL cholesterol, adding foods that are low in cholesterol and saturated fats will benefit since our bodies turn saturated fats into cholesterol. One can add grains and vegetables with a lean protein source (fish, chicken, turkey) into the main dish at lunch and dinner as well as beans to leafy salads, pasta salads and stews—chick peas, kidney beans and navy beans have been shown to reduce LDL cholesterol levels. Drinking fat-free or 1 percent milk, and eating low-fat/fat free yogurt and cheeses are shown to reduce LDL levels as well as overall cholesterol levels. Using oil in moderation helps lower risk of CAD. Olive oil or canola oil are recommended instead of oils high in polyunsaturated fats, such as corn oil, peanut oil and many margarines. Both olive oil and canola oil are high in monounsaturated fat, which decreases LDL and total cholesterol levels. Several studies also have shown that cooking with garlic reduces LDL-C and lowers blood pressure. Eating moderate amounts of nuts that are rich in monounsaturated fat, like hazelnuts, almonds, pecans, cashews, walnuts and macadamia nuts have too been shown to improve cholesterol levels (6,7). Presentation and Discussion of Patient: Mrs. E.M. was admitted to Wayne Memorial Hospital on October 15, 2018 with shortness of breath that she has experienced for several days prior. The patient is a 73 year old Caucasian female with a past medical history of obesity, Hypertension, Hyperlipidemia, Osteoarthritis, DM II and Irritable Bowel Syndrome (IBS). Her brother had a blood disorder and both her sister and mother had breast cancer. Her past surgical history included a cholecystectomy, appendectomy and a hernia repair. E.M. stated that she is allergic to Penicillin, Tetanus Vaccines and Toxoid, codeine and morphine. E.M. is 62” and weighed 317 lbs with a BMI of 58.0 kg/m^2 on admission. She denied any use of tobacco, alcohol or illicit drug use. E.M. is independent and has an active functional status. She is divorced and is living at home with her brother who she grocery shops and prepares meals with. E.M. did not state her profession or highest level of education completed.Day 1:On the day of admission at Wayne Memorial Hospital, the patients chief complaint was dyspnea with exertion. She presented herself to the ER because this condition had been persisting over the past 3 days, especially with activity. E.M. stated that she gets bronchitis usually once a year so she felt her SOB may be related to that. She was admitted on an ADA and NAS diet due to her diagnosis of diabetes and CHF and consumed 100% of her meals this day. A chest/thorax CTA and chest X-ray were performed. Chronic changes were seen in the chest/thorax CTA as well as Atherosclerosis and there was no definite acute process shown in the chest X-ray. E.M.’s blood pressure was 231/113 in ED, her troponin 0.55 on admission and she had an elevated D-dimer of 0.75. For her recent updated labs, refer to table 2. Day 2:On day 2, or October 16, 2018, an EKG was performed on E.M. and revealed sinus tachycardia without ST or T wave changes. The physician got the impression that E.M. had a Non-ST Elevation Myocardial Infarction (NSTEMI). The physician assumed that her anginal equivalent was the cause of her scapular pain and SOB. A lexiscan nuclear stress test was ordered, however, E.M. was too large to fit under the nuclear camera so they went ahead and scheduled a cardiac catheterization for the next morning. Since a cath was going to be performed, she was made NPO until further notice. Before her diet changed she consumed 100% of all meals this day. The dietitian had to conduct a nutritional evaluation on her for her nutrition-related problem of morbid obesity. We calculated that her IBW is 110 lbs and with her admitted weight she was 287% of her IBW. We estimated that her calorie needs should be ~1300 kcals and her protein needs ~45 g/d. E.M. got started on aspirin, statin and a beta blocker. BP 130/82. For all of E.M.’s medications that she was admitted with, refer to table 1. Table 1 – E.M.’s MedicationsMedication NameDose Drug ClassNutrition InteractionAmlodipine Besylate (Norvasc)5 mg/dAntihypertensive, Antiangina, Ca channel blockerMay take with food to decrease GI distress. Decreases Na, EdemaAspirin81 mg/dAnalgesic, Antipyretic, Antiarthritic, NSAID, To prevent CVA or MIFood decreases rate of absorption. Insure adequate fluid intake/hydration. May cause gastric bleeding, N/V, black tarry stools. Clopidogrel Bisulfate (Plavix)75 mg/dPlatelet aggregation inhibitor, acute coronary syndrome treatmentMay cause N/V/D, abdominal pain, constipation. Insulin Glargine (Lantus Solostar)60 unit SUBCUT Human insulin analogDo not mix with any other insulin.Lisinopril (Zestril)40 mg/dAntihypertensive Insure adequate fluid intake/hydration. Decreases Na. Avoid salt subs. Decreased weight reported. Meloxicam (Mobic)15 mg/dAntiarthritic, NSAIDCaution with GI irritants (K supplements). Increased risk of GI irritation. GERD, abdominal pain, diarrhea may occur. Metoprolol Tartrate (Lopressor)50 mg PO BIDAntihypertensive, Antiangina, CHF treatmentDecrease Na.Nausea, diarrhea, constipation may occur.Nitroglycerin (Nitroquick 0.4 mg)0.4 mg AntianginaN/V, abdominal pain may occur.Omega-3/Dha/Epa/Fish oil3 cap POAntihyperlipidemicDrug is adjunct to low fat, low sugar diet.Diarrhea may occur with high dose.Simvastatin (Zocor)5 mg POAntihyperlipidemicDecreases fat absorption, decreases cholesterol.Nausea, abdominal pain, constipation, diarrhea may occur.Day 3:On day 3, 10/17/18, the physician wrote a progress note stating that E.M. was seen and examined in follow-up for NSTEMI and uncontrolled hypertension. A cardiac catheterization was performed and revealed multi-vessel disease. She consumed 100% of her meal at 14:20 and 0% at 22:06 because she was NPO. The dietitian and I would provide a diet review post cath. E.M. required CABG or high-risk PCI at a tertiary care center. She remained asymptomatic. She stated she felt well with no active dyspnea at rest or chest pain. BP 198/134. Aspirin, statin and ACEI were continued and a Plavix and beta blocker were added.Day 4: On day 4, 10/18/18, the physician saw and evaluated E.M. in her room while her brother was present. She stated that she overall felt well. She was ambulating and not experiencing significant SOB symptoms. She was back on an ADA and NAS diet and consumed 100% of all meals this day. The physician reviewed with her and her brother the findings of her catheterization showing multi-vessel coronary artery disease and the likelihood that she would not be a good candidate for surgical intervention. The possibility of her having a multi-vessel coronary stenting undertaken as opposed to surgical revascularization was discussed. Yesterday, her blood pressure was running high but 110/70 on this day was remarkedly better. Her medications at present were amlodipine (5 mg/d), aspirin (81 mg/d), atorvastatin (41 mg/d), clopidogrel (75 mg/d), lisinopril (40 mg/d) and metoprolol (50 mg/2x d). Later that day, the physician sent a consult to nutrition services to do CHF diet teaching with her and to document the intervention before she could be discharged. I went out to conduct the teaching and advised her to limit her sodium (salt) intake or choose low-sodium options and to swap high-fat foods for low-fat or no fat options. We discussed what she usually eats and a lot of it was high in fat. I actually ended up putting together a list of healthy alternatives for the high-fat foods she frequently consumes. Because she was morbidly obese, I was asked by the dietitian to encourage a healthy weight loss. I recommended E.M. to eat a healthy diet consisting of a protein, healthy fat and whole-grain carbohydrate at every meal, to drink plenty of fluids (H2O), to consume a protein choice with every chosen carbohydrate-filled snack and to exercise regularly for at least 30 mins/day. This would also be beneficial for her diagnosis of DM II. E.M. was very attentive with the education I provided her. Discharge Summary: E.M. was discharged to home the morning of 10/19/18 in good condition. Over the course of her stay, E.M. received a dose of IV Lasix and was started on heparin drip. She was not initially started on a beta blocker due to concurrent new decompensated CHF. She underwent a cardiac catheterization which revealed multi-vessel coronary artery stenosis. She was medically optimized and remained chest pain free prior to discharge. Because of her multi-vessel disease, she required high-risk PCI. This would be performed weeks in advance. E.M. was discharged on aspirin, Plavix, statin, beta blocker and ACEI along with sublingual nitroglycerin to use as needed. She was advised to incorporate exercise into her daily living but avoid strenuous activity, consume a diet low in sodium and fat, and to follow-up as directed. The chosen nutrition diagnostic PES statement for E.M. was impaired nutrient utilization (NC-2.1) related to a large consumption of fatty foods as evidenced by diagnosis of hyperlipidemia. Table 2 – Laboratory (Chemistry) NameResultDateSodium14510/18/18Potassium3.510/18/18Chloride110 HIndicates dehydration 10/18/18Carbon Dioxide28.010/18/18BUN1410/18/18Creatinine0.9510/18/18Est GFR (non-Af Amer)57.7 LCaused by severe dehydration10/18/18Glucose148 HShe does have DM, so this is an indicator of elevated Glucose. Her DM might not be well-controlled with food.10/18/18Hemoglobin A1C7.5 HGoal is <7.0% to avoid DM complications.10/11/16Calcium8.510/18/18Total Bilirubin0.7410/15/18AST1910/15/18ALT2910/15/18Alkaline Phosphatase9810/15/18Total Creatine Kinase8510/15/18CK-MB (CK-2)5.2 HCan be caused by damage to her heart muscles.10/15/18Troponin I1.28 HHigh due to CHF or MI.10/16/18B-Natriuretic Peptide192.9 HHigh due to CHF.10/15/18Total Protein6.810/15/18Albumin3.610/15/18Triglycerides7110/16/18Cholesterol125 L10/16/18Cholesterol Risk Factor2.3 L10/16/18LDL-Cholesterol56.010/16/18HDL-Cholesterol5510/16/18TSH0.35 LHer thyroid is overactive (hyperthyroid) and producing excess thyroid hormone.10/15/18Free T3 pg/mL2.8510/15/18Research:In a 2018 study conducted by Li-Min Lun and Chao Xuan, they found that serum uric acid (UA) is the final product of purine metabolism in humans. The presented study is aimed at identifying the potential association between serum UA and early-onset coronary artery disease (EOCAD). The study population consisted of 1093 EOCAD patients aged ≤50 years, and 1117 age- and sex-matched apparently healthy people served as controls. The concentrations of UA were measured by uricase method. The severity of CAD was evaluated by Gensini score. The mean serum level of UA was 5.843?±?1.479?mg/dl in EOCAD patients and 5.433?±?1.529?mg/dl in controls. Serum UA levels were significantly higher in the EOCAD group than those in the control group (P < 0.001) and was an independent risk factor for EOCAD (OR?=?1.100, 95% CI: 1.022-1.185). The early-onset myocardial infarction patients with 3-vessel disease had higher serum UA levels than those with 1- or 2-vessel disease. The serum UA levels of EOCAD patients with acute coronary syndrome were significantly higher than those with chronic coronary artery disease. EOCAD patients with hyperuricemia had higher Gensini scores than those without hyperuricemia. In addition, the serum UA levels were affected by fluid intake (P < 0.01) and were positively correlated with serum creatinine (r = 0.323) and weight (r = 0.327). The results showed that serum UA was an independent risk factor for EOCAD. The serum UA levels were associated with the presence and severity of EOCAD and suggested that UA may be involved in the progression of EOCAD (11). In another study (2018) by Kyohei Marume, Seiji Takashio, Toshiyuki Nagai, Kenichi Tsujita, Yoshihiko Saito, Tsutomu Yoshikawa, Toshihisa Anzai, they found that statins might be associated with improved survival in patients with heart failure with preserved ejection fraction (HFpEF). The effect of statins in HFpEF without coronary artery disease (CAD), however, remains unclear. From the JASPER registry, a multicenter, observational, prospective cohort with Japanese patients aged ≥20 years requiring hospitalization with acute HF and LVEF ≥50%, 414 patients without CAD were selected for outcome analysis. Based on prescription of statins at admission, they divided patients into the statin group (n=81) or no statin group (n=333). They were followed for 25 months. The association between statin use and primary (all-cause mortality) and secondary (non-cardiac death, cardiac death, or rehospitalization for HF) endpoints was assessed in the entire cohort and in a propensity score-matched cohort. In the propensity score-matched cohort, 3-year mortality was lower in the statin group (HR, 0.21; 95% CI: 0.06-0.72; P=0.014). The statin group had a significantly lower incidence of non-cardiac death (P=0.028) and rehospitalization for HF (P<0.001), but not cardiac death (P=0.593). The beneficial effect of statins on mortality did not have any significant interaction with cholesterol level or HF severity.Statin use has a beneficial effect on mortality in HFpEF without CAD. The present findings should be tested in an adequately powered randomized clinical trial (12). Summary: CAD is very common, but should not be ignored, because the case will worsen over time and is likely to cause serious complications if not treated. Acute coronary syndrome (ACS) occurs when a coronary artery plaque breaks off, causing sudden partial or complete blockage of another artery. It is important to take action early in the course of the disease to prevent this from happening. Treatment is more effective if one is diagnosed and begins the treatment in the early stages of the disease.Three lessons learned: Many different prescription medications to treat a heart infection or heart failure, including Aldosterone Antagonists (potassium-sparing diuretics), Angiotensin-Converting Enzyme (ACE) Inhibitors (relaxes blood vessels), Angiotensin II Receptor Blockers (dilates blood vessels), Angiotensin Receptor Neprilysin Inhibitors (ARNIs) (helps blood vessels dilate, improve blood flow to the heart, reduce the amount of salt the body retains, and lessen any strain on the heart), beta blockers (helps reduce BP by block epinephrine), Calcium Channel Blockers (block the effect of calcium on heart muscle cells and blood vessels), statins (used to lower cholesterol), etc.A coronary artery bypass graft (CABG) is used when your heart is blocked. I learned that in a CABG, the surgeon uses arteries or veins from your leg, arm, or chest to reroute blood around the blockage to your heart, allowing the blood and oxygen to flow more freely so your heart doesn't have to work so hard. A CABG can also help relieve chest pain (angina). There may be one or up to several grafts done, depending upon how much blockage there is. This surgery is used to treat heart failure, atherosclerotic disease, and arrhythmias, but my case study patient did not undergo this while at Wayne Memorial Hospital. I learned how to nutritionally speak with a patient about keeping heart disease symptoms at bay and preventing the condition from getting worse. Educating my case study patient about nutrition lifestyle factors to make, such as eating a diet that's rich in fruits, vegetables, and whole grains because they are good for the heart, focusing on lean sources of protein and fat-free or low-fat dairy products and watching cholesterol, fat, salt, and sugar intake too as well as weight control, actually helped me learn about how to prevent CAD or any heart disease for myself and others, too. BibliographyDehn T. Coronary Artery Stenosis. Ann R Surg Engl. 2006 May; 88(3): 265-269. Accessed November 19, 2018.Cappelletti A, Pessina A, Mazzavillani M, Margonato A. Multivessel Coronary Artery Disease: Atheroma Progression and Dynamic Component. HSR Proc Intensive Care Cardiovasc Anesth. 2009; 1(4): 47-51. Accessed November 19, 2018.Jones N. Multivessel Heart Disease. . Published November 9, 2016. Accessed November 20, 2018. ATrain Education. ATrain Education. Accessed November 20, 2018. Treatment Options for Coronary Artery Disease (CAD). The Society for Cardiovascular Angiography and Interventions. Published November 4, 2014. Accessed November 20, 2018. Masley SC. Dietary Therapy for Preventing and Treating Coronary Artery Disease. AAFP Home. Published March 15, 1998. Accessed November 20, 2018. Good Nutrition Can Prevent and Treat Coronary Artery Disease. AAFP Home. Published March 15, 1998. Accessed November 20, 2018. Fogoros RN. An Overview of Heart Disease. Verywell Health. Accessed November 20, 2018. Sanfuentes B, Bulnes JF. Ranolazine as an Additional Antianginal Therapy in Patients with Stable Symptomatic Coronary Artery Disease. Published November 12, 2018. Accessed November 20, 2018.Fountoulaki K, Tsiodras S, Polyzogopoulou E, Parissis J. Beneficial Effects of Vaccination on Cardiovascular Events: Myocardial Infarction, Stroke, Heart Failure. Dermatopathology. Published November 14, 2018. Accessed November 20, 2018. Lun LM, Xuan C. Serum Uric Acid as an Independent Risk Factor for the Presence and Severity of Early-Onset Coronary Artery Disease: A Case-Control Study. Published October 23, 2018. Accessed November 20, 2018.Marume K, Takashio S, Nagai T, et al. Effect of Statins on Mortality in Heart Failure With Preserved Ejection Fraction Without Coronary Artery Disease　― Report From the JASPER Study ―. Acoustical Science and Technology. November 9, 2018. Accessed November 20, 2018. Brandao, S. Comparative Cost-Effectiveness of Surgery, Angioplasty, or Medical Therapy in Patients with Multivessel Coronary Artery Disease: MASS II Trial. Published November 3, 2018. Accessed November 20, 2018. ................
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