The Effectiveness Of Ischemic Heart Disease Essay
The Effectiveness Of Ischemic Heart Disease Essay
This chapter describes the methodology adopted in this study to assess the effectiveness of Ischemic Heart Disease (IHD) education package on knowledge and attitude regarding myocardial infarction among people at risk at Omayal Achi Community Health Centre, Arakampakkam, Chennai.
This phase of the study included selecting a research design, variables, setting of the study, population, sample, criteria for sample selection, sample size, sampling technique, development and description of the tool, content validity, pilot study, reliability of the tool, procedure for data collection and plan for data analysis.
3.1 RESEARCH APPROACH
The research approach used in the study was Quantitative Research Approach.
3.2 RESEARCH DESIGN
The Research Design adopted for this study was pre-experimental One group – Pretest and Post test design. The Effectiveness Of Ischemic Heart Disease Essay.
Group
Pretest
O1
Intervention
X
Post test
O2
People at risk for myocardial infarction identified by the tool prepared by the investigator based on Framingham cardiovascular disease risk assessment tool
Pretest level of knowledge and attitude regarding myocardial infarction among people at risk.
Ischemic heart disease (IHD) education package, a Information Education Communication( (IEC) on myocardial infarction in which,
Information:
Is given through Lecture method which consists of meaning, causes, risk factors, manifestations, diagnostic measures, management, complications, prevention and emergency health care services of Myocardial infarction devised by the investigator.
ORDER A PLAGIARISM-FREE PAPER NOW
Education:
Is given through video assisted learning which consists of prevention and emergency health care services of Myocardial infarction devised by the investigator.
Communication:
Is done through booklet which consists of meaning, causes, risk factors, manifestations, diagnostic measures, management, complications prevention and emergency health care services of Myocardial infarction devised by the investigator, (local language-Tamil)
Posttest level of knowledge and attitude regarding myocardial infarction among people at risk
3.3 VARIABLES
3.3.1 Independent Variable
Ischemic Heart Disease (IHD) education package
3.3.2 Dependent Variables
Knowledge and attitude regarding myocardial infarction among people at risk.
3.3.3 Extraneous Variables
Age in years, gender, religion, educational status, occupation, income, marital status, family history, personal habits, type of chronic disease, years of dealing with chronic disease, place of treatment, duration of treatment and knowledge regarding myocardial infarction.
3.4 SETTING OF THE STUDY
The study was conducted at Omayal Achi Community Health Centre at Arakampakkam, Chennai which has adopted 43 villages rendering comprehensive health care services to 49,000 population.
3.5 POPULATION
3.5.1 Target Population
The target population for the study were all the people who are at risk for myocardial infarction
3.5.2 Accessible Population
Accessible population for the study were all the people at risk visiting OPD at Omayal Achi Community Health Centre.
3.6 SAMPLE
The people at risk for myocardial infarction who fulfilled the inclusive criteria were the samples for this study. The Effectiveness Of Ischemic Heart Disease Essay.
3.7 SAMPLE SIZE
The sample size for this study comprised of 100 male and female adults who fulfilled the inclusive criteria
3.8 SAMPLING TECHNIQUE
As people only at risk to be the samples Purposive sampling technique was adopted for this study.
3.9 CRITERIA FOR SAMPLE SELECTION
3.9.1 Inclusive Criteria
People who are willing to participate.
People who are able to comprehend and respond the questions.
People who are between the age group of 30-70yrs.
3.9.2 Exclusive Criteria
People who are having sensory impairment.
People who already attended educational programme regarding cardio vascular disease.
People who are at risk and not attended the OPD at Omayal Achi Community Health centre during the time of data collection.
3.10 Development and description of the tool
After an extensive review of literature and discussion with experts, a structured questionnaire was constructed as a tool for the study.
The tool constructed in this study was constructed in to two parts.
3.10.1 Part – A:
Demographic variables of people at risk for myocardial infarction like age, gender, Education, Occupation, Family History, Marital Status, Personal habits, type of chronic disease, Years of dealing with chronic diseases, place of treatment, duration of treatment and knowledge regarding myocardial infarction.
3.10.2 Part – B:
3.10.2.1 Knowledge
Structured questionnaire to assess the level of knowledge regarding myocardial infarction among people at risk. It consisted of 20 Structured Interview schedule based on knowledge regarding myocardial infarction. The Questions were segregated as follows.
S.No.
Questions
Number of Items
1.
Meaning of Myocardial infarction
2
2.
Causes and Risk factors of Myocardial infarction
5
3.
Clinical Manifestations and Diagnostic Measures of Myocardial infarction
4
4.
Complication of Myocardial infarction
I
5.
Emergency health care services of Myocardial infarction
1
6.
Prevention of Myocardial infarction
7
Total
20
Scoring Key
The Structured questionnaire consisted of totally multiple choice Questions having one correct answer, hence each correct answer will be given one mark, and wrong answer will be given (0) mark. Thus totaling maximum of 30 marks to interpret the level of knowledge. The raw score was converted to percentage to interpret the level of knowledge. The level of knowledge were categorized as
< 50% – Inadequate level of knowledge.
51 – 75% – Moderately adequate level of knowledge
>75% – Adequate level of knowledge.
Attitude
Four point likert scale was used to assess the attitude on myocardial infarction among people at risk . The Effectiveness Of Ischemic Heart Disease Essay
Scoring Key
Modified 4 points likert scale consisted of 10 statements to assess the attitude towards myocardial infarction among people at risk. Out of 10 statements, 5 statements were positively worded. The raw score was converted to percentage to interpret the level of attitude.
The scoring for Positive and Negative statements are given Below.
S.No.
Questions
Strongly agree
Agree
Disagree
Strongly disagree
1.
Positive
4
3
2
1
2.
Negative
1
2
3
4
< 50% – Unfavorable attitude
50 – 75% – Moderately favorable attitude
< 75% – Favorable attitude
3.11 CONTENT VALIDITY
The content validity of the data collection and intervention tool was ascertained by opinion from experts in the field of community health nursing and community medicine.
Modifications were made as per the experts suggestions and were incorporated in the tool to conduct the main study.
3.12 ETHICAL CONSIDERATION
The ethical principle followed in study were
Beneficiary
3.12.1 Freedom from Harm and Discomfort
The study participants were not subjected to necessary risks for harm during study period.
3.12.2 Respect for Human Dignity
The participants were given full rights to ask question, refuse to give information and also to withdraw from the study.
Written consent form was obtained from the participants initially for the willingness to participate in the study.
3.12.3 Protection from Exploitation
The participants were assured that their participation or information they provided would not be used to harm them any way. The Effectiveness Of Ischemic Heart Disease Essay.
.4 Justice
The selection of study participants was completely based on research requirements. A full privacy was maintained through the process of data collection.
3.13 PILOT STUDY
The pilot study is the trial run for major study. The pilot study was conducted after obtaining the formal permission from the Principal, Omayal Achi College of Nursing and the councilor of Gudiyattam Taluk. The investigator conducted the pilot study by selecting 10 samples who fulfilled the inclusive criteria. The pilot study was conducted for the period of one week.
The investigator introduced the study to the people at risk and obtained the written consent for their willingness to participate in the study and to take the blood sample to check the serum cholesterol level. The investigator explained the purpose of the study and reassured them on the confidentiality of the information being given during the study. The people were made to sit comfortably in well ventilated room, the investigator sat face to face for conducting the pretest by using structured interview schedule and 4 point likert attitude scale on myocardial infarction. It took about 45mins for assessing the knowledge and attitude regarding myocardial infarction. The Ischemic Heart Disease (IHD) education package was given for about 30mins after the pretest. The 10 people at risk were made to gather in the common place for the intervention of Ischemic Heart Disease (IHD) education package. Post test was done after 7 days to assess the mean improvement in knowledge and attitude on myocardial infarction among people at risk .
The gathered pilot study data was analyzed using both descriptive and inferential statistics. There was high statistically difference in the pre and post test result with ‘t’ value 9.00 at p< 0.001. The findings of the reliability test revealed that the tool was feasible to conduct the main study.
3.14 RELIABILITY
The reliability of the tool was established by using test-retest method for knowledge related questions and split half method was used for the attitude statements. The reliability score was r= 0.84 for knowledge and r=0.96 for attitude scale. It was highly reliable for the researcher to continue with the main study.
3.15 Data Collection procedure
Prior Permission was obtained from the Higher authorities of the college. HOD of Department of Community health Nursing and also from the Incharge Omayal Achi Community Health Centre where the study was conducted.
Investigator introduced self to the study population. An informed and written consent was obtained from each people prior to data collection. After giving Brief introduction and explanation on how to answer the Questions to the participants, the data was collected. Confidentiality was strictly maintained during the process of data collection The people were made to sit comfortably in well ventilated room, the investigator sat face to face for conducting the pretest by using structured interview schedule and 4 point likert attitude scale on myocardial infarction. It took about 45mins for assessing the knowledge and attitude regarding myocardial infarction.The Effectiveness Of Ischemic Heart Disease Essay. The Ischemic Heart Disease (IHD) education package package was given for about 30mins after the pretest. The people at risk were made to gather in the common place for the intervention of Ischemic Heart Disease (IHD) education package. Post test was done after 7 days to assess the mean improvement in knowledge and attitude on myocardial infarction among people at risk , and the data was collected during the stipulated period of 4 weeks.
3.16 Plan for data analysis
The data was analyzed by descriptive and Inferential statistics.
3.16.1 Descriptive Statistics
Frequency and percentage distribution was used to analyze the demographic variables.
Mean and standard deviation is used to analyze the pre and post test level of knowledge and attitude.
3.16.2 Inferential Statistics
Paired ‘t’ test was used to compare the pre and post test level of knowledge and attitude.
Karl Pearson’s correlation to find out the relation between the knowledge and attitude.
Anova to associate the mean differed level of knowledge and attitude with the selected demographic variables.
Mr. MS is a 58-year-old Malay male who was previously diagnosed with hypertension, gout and triple vessel ischemic heart disease. He first presented with chest pain in March 2010 where he was diagnosed with ischemic heart disease. He was unable to complete an exercise stress test and an angiogram done in Hospital Sultanah Aminah found him to have triple vessel disease. He was told angioplasty was not possible due to the severity of the blocks and was counseled for CABG but he was not keen. Meanwhile, he has had angina attacks 2 to 3 times per week every week since his initial diagnosis for the last 3 months, usually relieved by sublingual GTN and was currently admitted for the 4th time for chest pain not relieved by GTN. ECG done 2 hours after onset of chest pain showed ST depression of 2mm at leads I, aVL, V3 – V6 and left axis deviation with no Q waves. The Effectiveness Of Ischemic Heart Disease Essay.Trop T was positive (2.75 ng/ml) at 4 hours after onset and other cardiac enzymes were also raised significantly. He was diagnosed with NSTEMI and treated with aspirin 300mg, IV morphine 2.5 mg, sublingual GTN 3 tablets and subcutaneous clexane 60mg BD for 3 days as well as continuing his current medication regime of simvastatin, metoprolol, cardiprin, ISDN, amlodipine and GTN. Following admission, he was well in the ward with no recurrence of chest pain and did not develop any new complaints. He was discharged after 3 days of inpatient treatment with instructions to attend his follow-up appointment at the cardio clinic in HSAJB on the 16th of June 2010 to make an appointment for surgery. Following this episode of chest pain, which he says is the worst so far, he is now quite keen for CABG.
2) CLINICAL HISTORY
Chief Complaint
Chest pain for 1 day.
History of Present Illness
Mr. MS is a 58-year-old Malay male who was previously diagnosed with gout, hypertension and ischemic heart disease with triple vessel disease. He was awoken from sleep at about 10pm due to a central chest pain of sudden onset. He described the character of the pain as crushing in nature and radiated to his neck. This episode of chest pain was the most severe since he was first diagnosed with ischemic heart disease. The pain was associated with profuse sweating, body weakness and was not relieved by rest. However, it was relieved by sublingual GTN, of which he has a supply of. His discomfort was made worst by exertion so he lay in bed to recover. Despite this, he had another episode of chest pain 30 minutes later. He took the sublingual GTN again but this time, the pain did not resolve. He was then brought to the emergency department of Hospital Batu Pahat by his son. The Effectiveness Of Ischemic Heart Disease Essay.
This is Mr. MS’s fourth admission for chest pain since March 2010. Since his diagnosis of ischemic heart disease in March, he has experience angina attacks two to three times per week, especially on exertion such as when straining while passing motion. During these attacks, he uses sublingual GTN to relieve his symptoms and normally feels much better after that. He only comes to the hospital when GTN does not work to relieve his symptoms.
Systemic Review
Mr. MS does not experience symptoms such as palpitations, dizziness, headache, nausea, vomiting, orthopnoea, paroxysmal nocturnal dyspnoea, epigastric pain, shortness of breath, fever, and had no syncopal episodes. He also does not have loss of appetite or loss of weight. Bowel and urinary habits are normal. His sleep has not been affected until this current episode whereby he was awoken by the chest pain.
Past Medical History
Mr. MS was diagnosed with hypertension 6 years ago when he had an episode of headache. He has been on medication since and was on regular follow-up with KK Rengit. He was diagnosed with gout 5 years ago when he had a left big toe swelling which resolved after some medication. He is not on long term medication for gout. Mr. MS was admitted for the first time 5 years ago in 2005 when he had bilateral renal calculi. He was subsequently referred to Hospital Sultanah Aminah for further management of this problem and it has since resolved and does not have follow-up anymore.
Mr. MS was diagnosed with ischemic heart disease in March 2010 when he presented with chest pain for the first time. The Effectiveness Of Ischemic Heart Disease Essay. Following his recovery, he underwent a stress test in Hospital Batu Pahat but according to him, was unable to complete the procedure due to chest discomfort. He was referred to the cardiology unit in Hospital Sultanah Aminah for further management where an angiogram was performed and he was told to have triple vessel disease. He was also told that angioplasty was not possible due to the severity of the blocks. He was recommended to have Coronary Artery Bypass Grafting (CABG) but as of yet, no appointment has been made as he was still unsure of going through with the procedure. Following this episode of chest pain, Mr. MS has decided that going for the CABG is the only thing that will keep him alive.
His current medications include:
Tab Simvastatin 20mg OD
Tab Metoprolol 75mg BD
Tab Cardiprin 100mg OD
Tab Isosorbide Dinitrate (ISDN) 5mg TDS
Tab Amlodipine 10mg OD
Sublingual Glyceryl Trinitrate (GTN) PRN
He is compliant to his medication regime.
Mr. MS is not known to have diabetes or hyperlipidemia. He also does not have any known food or drug allergies.
Family History
Mr. MS is the 3rd of 9 siblings. His father had hypertension and passed away a long time ago due to unknown causes. His mother and other siblings are healthy. None of them have hypertension, diabetes, ischemic heart disease or malignancy.
Social History
He lives in a kampung in Rengit with his wife and 5 children. Mr. MS does not smoke nor consume alcohol. He works in a palm oil plantation. The distance from his house to Hospital Batu Pahat is about half an hour. On further enquiry, Mr. MS says that the cost of the CABG is about RM1000, which he can afford. The Effectiveness Of Ischemic Heart Disease Essay.
3) FINDINGS ON CLINICAL EXAMINATION
(Mr. MS was examined by me 9 hours after onset of chest pain)
Mr. MS was alert, conscious, and communicative. He was not in obvious pain or respiratory distress. He was lying down comfortably on his bed. There were no tendon xanthomata, xanthelasma, pallor, corneal arcus or pedal edema. His JVP was not raised. His clinical parameters are:
Blood Pressure : 158/94 mmHg
Heart Rate : 94 beats per minute. Regular rhythm
Respiratory Rate : 20 breaths per minute
Temperature : 37°C
SpO2 : 97% under room air
On examination of the precordium, the apex beat was located at the 5th intercostal space on the midclavicular line and was normal in character. Parasternal heave was not felt and there were no thrills. First and second heart sounds were heard. There were no murmurs or added heart sounds.
On examination of the chest, there was no deformity and chest expansion was equal on both sides. Percussion and tactile vocal fremitus was normal and equal on both sides. On auscultation, vesicular breath sounds were heard throughout all lung fields with good air entry. There was no wheezing or crepitations heard. The Effectiveness Of Ischemic Heart Disease Essay.
On examination of the abdomen, it was soft and non-tender. There were no masses felt. Bowel sounds were heard and normal.
4) PROVISIONAL AND DIFFERENTIAL DIAGNOSES WITH REASONING
Provisional Diagnosis
Acute myocardial infarction with underlying triple vessel ischemic heart disease and hypertension
With a history of diagnosed triple vessel ischemic heart disease with multiple episodes of angina attacks since the initial diagnosis, it is highly likely that Mr. MS is presenting with an acute coronary event and this should be a priority until proven otherwise. The Effectiveness Of Ischemic Heart Disease Essay. This is evidenced by the presentation of central, crushing chest pain of sudden onset that radiated to the neck and associated with profuse sweating and body weakness which is classical of a myocardial infarction. Mr. MS will require immediate investigations such as an electrocardiogram and cardiac enzymes to differentiate the acute coronary syndromes so that the appropriate management may be instituted for him e.g. if he has an ST-segment elevation myocardial infarction (STEMI), he will require myocardium-saving thrombolytic therapy to disrupt the ischemic event. As Mr. MS did not present with features such as acute shortness of breath, loss of consciousness and severe palpitations, it seems that he does not have complications of acute myocardial infarction but these developments should be watched out for throughout his admission as complications may arise later.
Differential Diagnosis
Pulmonary embolism
Pulmonary embolism is a possibility that can be considered when a patient presents with an acute chest pain that is accompanied by shortness of breath, hemoptysis, tachypnea, fever and even cyanosis and collapse in severe cases. Furthermore, the chest pain is of a pleuritic nature, of which it is worsened on breathing, and a pleural rub can be heard on auscultation of the chest. However, Mr. MS did not present in such a way. At the same time, Mr. MS did not have risk factors such as a deep vein thrombosis, prolonged immobilization or recent surgery. It is still highly likely that Mr. MS has suffered an acute myocardial infarction, and an ECG would help to differentiate between the two as pulmonary embolism might show the classic S1Q3T3 pattern of right axis deviation or right bundle branch block. Either way, the diagnosis should be made quickly so treatment may be instituted before his condition becomes worse or complications develop. The Effectiveness Of Ischemic Heart Disease Essay.
Aortic dissection
Aortic dissection presents as an acute onset chest pain that is tearing in nature, and often radiates to the back. It is often confused with myocardial infarction due to its presentation but differences include the lack of profuse sweating, signs of heart pump dysfunction and a normal ECG. Risk factors are usually uncontrolled hypertension, connective tissue disorders or chest trauma. Mr. MS has hypertension, but is under control, and does not have the other risk factors. A diagnosis of myocardial infarction should be the priority as thrombolytic therapy is vital, but if there is any reason to doubt that diagnosis, then further investigations should be performed.
5) IDENTIFY AND PRIORITISE THE PROBLEMS
1. Acute chest pain
Mr. MS has acute chest pain with features very suggestive of a classical picture of myocardial infarction as he presents with crushing central chest pain that radiates to the neck and associated with profuse sweating and weakness. Given that he is known to have triple vessel ischemic heart disease and that he has suffered many angina attacks since his initial diagnosis, it is highly likely that he is having an acute myocardial infarction. Without further a due, he needs an electrocardiogram (ECG) and cardiac enzymes tested to distinguish between the different acute coronary syndromes so that the appropriate treatment protocols may be initiated for him as soon as possible to disrupt the ongoing ischemia. As Mr. MS is having severe chest pain that may overstimulate his sympathetic system and cause further ischemia, he will require immediate supportive therapy such as effective pain medication and oxygen therapy.
2. Triple vessel ischemic heart disease awaiting CABG
Mr. MS was diagnosed with triple vessel ischemic heart disease when he first presented with chest pain in March 2010 and has since experienced many episodes of angina. Given his diagnosis and disease pattern, he is at a very high risk of developing a severe acute coronary event that may prove fatal if the infarction is too extensive or if complications develop. The Effectiveness Of Ischemic Heart Disease Essay. As percutaneous revascularization with a stent or balloon was not possible for him, he will require a CABG to both relieve his symptoms and reduce his mortality risks in the long term. He was unsure of going ahead with the operation previously, therefore no appointment date was given for surgery. However, now that he has changed his mind, every effort should be made by both the doctors in charge of him here in Hospital Batu Pahat and in the cardiology unit of Hospital Sultanah Aminah to arrange for his surgery as soon as possible, given the circumstances of his condition.
3. Compliance to medication
Mr. MS is on several medications for his triple vessel ischemic heart disease and will require revascularization surgery soon in order to decrease his mortality risks. However, waiting for a CABG in the government setting may take some time, even under dire circumstances due to the nature of the system. Therefore, it is extremely crucial that Mr. MS is compliant to his medication regime while awaiting a CABG to prevent another episode of infarction. He should be counseled to fully understand this and the situation of his ischemic heart disease. It is also the responsibility of his doctors to ensure that he is taking the right combination of medications with the aim to prevent another acute cardiac event. Meanwhile, a sufficient supply of sublingual GTN should be provided for Mr. MS in cases of angina attacks at home. He should come to the hospital immediately if GTN fails to relieve his symptoms.
4. Regular screening for comorbid diseases
Mr. MS has not been diagnosed with diabetes or hyperlipidemia previously but these diseases are strong risk factors for the long term implications of his ischemic heart disease. Therefore, Mr. MS should be screened regularly e.g. twice yearly during his follow-up appointments. Early detection of diabetes is necessary so that treatment can start as soon as detected in order to prevent his ischemic heart disease from becoming worst than it already is. As for his lipid control, if his lipid profile is found to be outside the normal limits, the dosage of his medication can be increased as necessary. Following his CABG, he will need to maintain a healthy lifestyle of a good, well-balanced, low-salt and low-fat diet and regular exercise within his limits. The Effectiveness Of Ischemic Heart Disease Essay.
6) PLAN OF INVESTIGATION, JUSTIFICATIONS FOR THE SELECTION OF TESTS OR PROCEDURES, AND INTERPRETATION OF RESULTS
1. Electrocardiogram (ECG)
To look for any changes that may indicate an ongoing ischemic event, such as ST elevation or depression and T wave inversion in order to support the diagnosis of an acute myocardial infarction so appropriate treatment can be started. Differentiation of ST segment elevation or depression is also crucial in initiating treatment as thrombolytic therapy is only indicated for ST-elevation myocardial infarction.
Results: ECG on admission (2 hours after onset) shows sinus rhythm with ST depression at leads I, aVL, V3 – V6 with left axis deviation. T wave was present and normal.
Interpretation: The ST depression in the leads above indicate an ischemic event at the anterolateral sections of the heart. The lack of ST elevation concludes a diagnosis of either unstable angina or NSTEMI, depending on the levels of cardiac enzymes. There is no sign of old infarction. The Effectiveness Of Ischemic Heart Disease Essay.
2. Cardiac Enzymes
To look for elevated levels of cardiac enzymes such as troponin T, creatinine kinase (CK), lactate dehydrogenase (LDH) and aspartate transaminase (AST) that will indicate myocardium ischemia and necrosis. If elevated, a diagnosis of NSTEMI can be made in accordance with the ECG changes. However, cardiac enzymes when done too early after onset may not show any rise in levels 1. This does not mean that necrosis has not taken place and the test should be repeated once more at 6 hours after onset 1.
Results: Troponin T (4 hours after onset) – 2.75ng/ml ↑
(12 hours after onset) (60 hours after onset) Normal Range (U/L)
CK – 997 ↑ 263 ↑ <175
LDH – 392 ↑ 518 ↑ 114 – 241
AST – 139 ↑ 59 ↑ <37
Interpretation: Troponin T is elevated indicating myocardial infarction and necrosis has taken place, and combined with the features on ECG, a diagnosis of NSTEMI is made regarding Mr. MS’s current episode of chest pain.
3. Full Blood Count
To look for signs of infection or anemia which could have precipitated the acute coronary event, to check platelet levels as thrombolytic or anticoagulation therapy will be started for Mr. MS, and as baseline for monitoring as anticoagulation therapy with heparin may cause thrombocytopenia.
Result: TWBC – 13.7 x109/L ↑ (neutrophils – 59.2%, lymphocytes – 35.5%)
Hemoglobin – 13.7 g/dL
Platelets – 357 x 109/L
Interpretation: The total white cell count is raised, but that could be due to the reaction of the body towards the acute stressing event of the myocardial infarction. Hemoglobin is normal indicating no anemia and platelets are normal, therefore there is no contraindication to start anticoagulation therapy.
4. Prothrombin Time, INR, Activated Partial Thromboplastin Time (PT/INR/APTT)
To obtain a baseline of the coagulation profile before starting any anticoagulation or thrombolytic therapy.
Result: PT – 14.3s INR – 1.28 APTT – 42.6s
Interpretation: PT/INR/APTT is within normal range. There is no contraindication to anticoagulation or thrombolytic therapy if necessary.
5. Renal Profile
To assess the renal functions as the patient has a history of hypertension. Also, it is necessary to check renal functions before drugs such as ACE-inhibitors are started.
Result: Urea – 5.7mmol/L Sodium – 135mmol/L
Potassium – 4.1mmol/L Creatinine – 129µmol/L
Interpretation: Mr. MS’s renal functions are normal. There is no evidence of renal disease and drugs such as ACE-inhibitors may be added to his medication regime if required. The Effectiveness Of Ischemic Heart Disease Essay.
6. Chest X-Ray
Provides information of the left heart function by looking for cardiomegaly or increased pulmonary markings as Mr. MS has ischemic heart disease and hypertension. However, Mr. MS has no complaints suggestive of failure. Therefore, this chest radiograph may be used as a baseline for comparisons with future radiographs.
Result: There is no cardiomegaly and no features of pulmonary congestion.
Interpretation: Mr. MS’s left heart function is normal, as the lack of failure symptoms suggests.
7. Fasting Blood Glucose
To screen Mr. MS for diabetes, which is an important co-morbid condition and risk factor for his ischemic heart disease and will require early treatment if detected.
Result: 6.4mmol/L
Interpretation: The fasting blood glucose level is normal but is on the high end of the normal range. This could be the result of the body’s acute stress response to the myocardial infarction. Mr. MS should be screened regularly in future for diabetes given his high risk.
8. Fasting Lipid Profile
Despite the fact that Mr. MS was not previously diagnosed with hyperlipidemia, he is taking medication (simvastatin) as it is recommended for patients with ischemic heart disease. However, his lipids should be checked regularly to detect a rise in the cholesterol and LDL levels so that it can be managed appropriately.
Results: Total Cholesterol – 4.4mmol/L HDL – 1.3mmol/L
Triglycerides – 1.5mmol/L LDL – 2.4mmol/L
Interpretation: His fasting lipid profile is normal. This indicates that Mr. MS requires no adjustment to his medication for lipid control.
7) WORKING DIAGNOSIS AND PLAN OF MANAGEMENT ON ADMISSION
Working Diagnosis
Non ST-segment elevation myocardial infarction (NSTEMI) with underlying triple vessel ischemic heart disease and hypertension
Plan of management at the emergency department
Sublingual GTN 1 tablet stat
Tablet aspirin 300mg stat
Oxygen therapy 3L/min via nasal prong
Intravenous morphine 2.5mg stat
Intravenous drip 1 pint Normal Saline
Plan of management on admission to the ward
Subcutaneous clexane 60mg BD for 3 days
Sublingual GTN 1 tablet PRN
Oxygen therapy 3L/min via nasal prong
Encourage oral intake
Daily ECG and if chest pain recurs
Vital signs and SpO2 monitoring 2 hourly
Tablet simvastatin 20mg ON
Tablet metoprolol 75mg BD
Tablet cardiprin 100mg OD
Tablet isosorbide dinitrate (ISDN) 5mg TDS
Tablet amlodipine 10mg OD
To inform staff nurse or house officer immediately if symptoms recur. The Effectiveness Of Ischemic Heart Disease Essay.
8) SUMMARY OF INPATIENT PROGRESS (INCLUDING MAJOR EVENTS, CHANGE OF DIAGNOSIS OR MANAGEMENT AND OUTCOMES)
In the emergency department, Mr. MS was relatively stable on presentation despite the acute coronary event. He was given sublingual GTN 3 times in total in the emergency department before his symptoms were relieved. Upon admission to the ward, he was started on subcutaneous clexane and was continued on his current medication regime. Throughout Mr. MS’s stay in the ward, he did not have any recurrences of chest pain and did not develop any complications of his NSTEMI. He was relatively comfortable in the ward, did not have any new complaints, slept well at night and was able to tolerate well orally. His vital signs were also stable throughout his stay. Daily ECG showed resolving ST changes with no new evolving changes.The Effectiveness Of Ischemic Heart Disease Essay. He was discharged after 3 days of inpatient treatment whereby he completed three days of subcutaneous clexane. ECG taken on discharge showed T wave inversion in leads I and aVL, ST depression in leads V4 to V6 and Q waves in leads V4 to V6. On discharge, he was given appointment at the specialist clinic in Hospital Batu Pahat to review his renal profile, fasting blood glucose and fasting lipid profile in 3 months time. He was also told to continue his current medication regime and his follow-up appointment with the cardiology clinic in Hospital Sultanah Aminah on the 16th of June 2010 to fix a date for his CABG.
9) DISCHARGE PLAN, COUNSELLING AND MOCK PRESCRIPTION
Discharge Plan
Continue current medication regime.
Follow-up appointment with specialist clinic, Hospital Batu Pahat in 3 months time to review renal profile, fasting blood glucose, and fasting lipid profile.
Follow-up appointment with cardiology clinic, Hospital Sultanah Aminah on 16/6/2010 to fix a date for CABG.
Suggested Additional Discharge Plan:
Add Tab. Clopidogrel 75mg OD 1. Consider adding Tab. Trimetazidine 35mg BD 2.
Counseling
Advised compliance to medications to prevent further recurrence of chest pain.
Advised to return immediately to the hospital if Mr. MS suffers from chest pain that is not relieved by GTN or other worrying symptoms.
Advised to watch a healthy lifestyle in order to prevent other comorbid conditions such as hyperlipidemia and diabetes. At the same time, healthy living confers benefits and reduces mortality risks of ischemic heart disease.
Mock Prescription
Tab. Simvastatin 20mg ON x 3/12
Tab. Metoprolol 75mg BD x 3/12
Tab. Cardiprin 100mg OD x 3/12
Tab. Isosorbide Dinitrate (ISDN) 5mg TDS x 3/12
Tab. Amlodipine 10mg OD x 3/12
S/L GTN 1 tablet PRN x 3/12
10) REFERRAL LETTER (IF APPLICABLE)
Cardiologist,
Cardiology Clinic,
Hospital Sultanah Aminah, Johor Bahru. 5th June 2010
Mr. MS (IC.510831015263)
Date of admission: 3rd June 2010, Date of discharge: 5th June 2010
Problem: Triple Vessel Ischemic Heart Disease for CABG
Dear doctor, The Effectiveness Of Ischemic Heart Disease Essay.
Mr. MS is a 58-year-old gentleman who is under your follow-up for triple vessel ischemic heart disease. He presented to us with acute chest pain not relieved by GTN. He was diagnosed with NSTEMI as ECG on admission showed ST depression (2mm) in leads I, aVL, V3 – V6, and cardiac enzymes were positive. He was admitted for 3 days during which he was treated with subcutaneous clexane 60mg BD for 3 days and continued his current medications of simvastatin 20mg ON, metoprolol 75md BD, cardiprin 100mg OD, ISDN 5mg TDS, amlodipine 10mg OD and GTN 1 tablet PRN. During his stay, he did not have recurrence of chest pain and was relatively comfortable throughout. We discharged him with instructions to attend your clinic as scheduled on the 16th of June 2010. It is our understanding that he was recommended CABG but was not keen initially. However, that has changed. Please review his condition during his follow-up with you and if possible, to fix a date for CABG. Thank you very much for your attention.
Yours sincerely,
Paul Kong Fu-Xiang (Final year medical student, IMU),
Department of Medicine, Hospital Batu Pahat.
11) LEARNING ISSUES IN THE 8 IMU OUTCOMES
1. Critical thinking and research
Mr. MS is on many medications for his ischemic heart disease. However, he suffered frequent recurrent angina attacks despite this. The worry is that after discharge, he may continue to suffer from angina attacks, or worse still, another myocardial infarction. This issue explores the benefits of adding the anti-anginal medication trimetazidine to his medication regime.
(Worksheet attached below)
Trimetazidine is a relatively new anti-anginal medication which works to prevent ischemia by counteracting the major metabolic disorders occurring within the ischemic cell such as acidosis, disturbance of transmembrane ion exchange and the production of free radicals. The Effectiveness Of Ischemic Heart Disease Essay. In the systematic review by Ciapponi et al 2, 23 studies were included to determine the efficacy and tolerability of trimetazidine in patients with stable angina. Trimetazidine in these studies were compared with either monotherapy versus placebo or another anti-anginal agent, or in combination therapy versus regimes without trimetazidine. The two main outcomes measured were the frequency of angina attacks and the frequency of GTN use. Trimetazidine was shown to reduce angina attacks per week by 40% independent of whether it was given in mono or combination therapy, but confidence intervals were wide. This study also showed that GTN use was reduced by a mean of 1.47, a finding that supports the efficacy of adding trimetazidine to anti-anginal therapy. This study also showed that trimetazidine appeared to be better tolerated by patients in terms of adverse effects when compared to other medications in combination therapy from the dropout rate of some trials. However, this information is limited by the lack of trials directly comparing the safety profile of trimetazidine versus beta blockers, calcium channel blockers, or nitrates. Furthermore, there is little information in the literature about trimetazidine and its effect on mortality, cardiovascular events, or quality of life. The authors recommend long term trials comparing trimetazidine with other anti-anginal agents using clinically important outcomes such as the above. In conclusion, there appears to be some benefit in adding trimetazidine to Mr. MS’s medication regime in a bid to reduce the frequency of his angina attacks, but there is no evidence to suggest that it confers better protection in terms of long term mortality, cardiovascular events, and quality of life. The Effectiveness Of Ischemic Heart Disease Essay.
2. Self directed life-long learning and information management
Beta blockers, calcium channel blockers and nitrates have long been the mainstay of anti-anginal medication. However, ranolazine has recently been approved as an anti-anginal agent 3. This issue explores its benefits.
ORDER A PLAGIARISM-FREE PAPER NOW
Ranolazine was approved by the US Food and Drug Administration (FDA) on 31st January 2006, the first new drug approved for the treatment of chronic angina in over a decade 3 and a new class of anti-anginal agent in almost 25 years 4. Ranolazine is an orally active piperazine derivative. Its mechanism of action is not fully understood, but its known to inhibit myocardial fatty acid oxidation, resulting in preferential glucose oxidation leading to a decrease need for oxygen for a given level in the glucose pathway that translates into an anti-ischemic action whereby there is increased oxygen efficiency in the myocardium 4. It is metabolized in the liver and excreted in the urine. Therefore, it is contraindicated for patients with any form of liver impairment 4. It also shows drug interactions with drugs such as digoxin and simvastatin 4. The first large placebo-controlled trial to establish a dose-response anti-anginal relationship of ranolazine monotherapy was the MARISA trial 5 in 2004 by Chaitman et al. They demonstrated that in patients taking ranolazine, there was a significant dose-related increase in the exercise capacity of patients known to have exercise restrictions from angina 5. The follow up CARISA trial combined the use of ranolazine with beta blockers of calcium channel blockers and found that there was a significant increase of exercise duration independent of background anti-anginal therapy 6. They also recorded a siginificantly reduced use of GTN by the patients in the ranolazine group 6. The ERICA trial was a double-blind study of 565 patients to determine the benefits of ranolazine in chronic angina in patients already on maximum recommended doses of amlodipine 7. The primary endpoints of their study were the number of angina attacks and GTN consumption per week.The Effectiveness Of Ischemic Heart Disease Essay. They also addressed safety issues of ranolazine via assessment of side effects and ECG. They found that ranolazine significantly reduced the frequency of angina attacks and GTN use per week and also found that ranolazine appeared to have a more pronounce effect in patients with more frequent angina attacks 7. They also reported that ranolazine was well tolerated. It was these results of the ERICA trial that satisfied the FDA that ranolazine offered some benefit over the current standard therapies 4. However, Anderson et al raised the issue of side effects of ranolazine as dose-related prolongation of the QT interval on ECG but could not associate this with any incidences of ventricular arrhythmia 8. Due to these findings, FDA approval of the use of ranolazine is limited to patients who have not responded ideally to other drugs and to be used in combination therapy 4. However, the later MERLIN-TIMI 36 trial 9 found that the addition of ranolazine to combination therapy did not significantly improve mortality or cardiovascular events. At the same time though, they showed that ranolazine did not increase the risk of all-cause mortality or symptomatic documented arrhythmias, thus supporting ranolazine’s safety profile 9. This new information, together with that of the CARISA extension study 10 that showed ranolazine’s effect in improving glycemic control in diabetic patients included in the study, prompted its developer, CV Therapeutics to apply to the FDA to change the indications of ranolazine to that of a first-line anti-anginal agent with benefits in HbA1c and arrhythmia reduction. The FDA approved this in November 2008. In conclusion, the addition of ranolazine to Mr. MS’s medication regime may confer some benefit in reducing the number of angina attacks, but seems similar as the use of trimetazidine. However, ranolazine is not available in our setting. The Effectiveness Of Ischemic Heart Disease Essay.
3. Disease prevention and health promotion
Mr. MS has just suffered a NSTEMI. He also has a history of frequent angina attacks. What are his risks of developing another serious cardiac event?
Mr. MS has triple vessel ischemic heart disease with frequent angina attacks over the last few months and has just suffered a NSTEMI. His chances of survival without some form of definitive intervention sounds quite low, but how does this translate into statistics?
Using the model of the TIMI risk scoring of unstable angina and NSTEMI 11 in predict. The Effectiveness Of Ischemic Heart Disease Essay.
