Clive’s myocardial infarction

Scenario:

Mr Clive Jenkins

Consider the Patient Situation

Mr Clive Jenkins is a 78 years-old retired navy engineer. He has a past medical history of Congestive Cardiac Failure (CCF). This developed after he experienced a severe myocardial infarction 2 years ago. Both ventricles were affected.

The recent death of several close friends has made it difficult for Clive to be concordant with his CCF management and sustain the necessary life-style adjustments required to prevent exacerbations. This has resulted in several admissions to hospital for management and review of his CCF.

For this current admission, Mr Jenkins was referred to hospital by his GP after recently rapidly gaining weight (currently 95kg), since his last visit the previous week.

The time now is 0800 and you have just come on for your morning shift. Mr Jenkins has been on the ward for only two hours after spending approximately 12 hours in emergency waiting for a bed to become available.

Mr Jenkins appears slightly disoriented. When repositioning himself in bed you observe that he becomes short of breath. You ask him if he will get out of bed for breakfast but he is reluctant to mobilise as he feels so tired. You also note that his water jug is empty.

Upon undertaking a further assessment of Mr. Jenkins, you obtain the following new information:

Vital Signs
RR: 24
Sp02: 94% on 2lt via nasal prongs
BP: 150/90
HR: 112bpm
Temp: 36.5oC

Other information
BGL within normal range
GCS 14 – Eye opening – 4; Verbal response – 4; Best motor response – 6

Hydration status assessment
Peripheral pulses difficult to palpate
Presence of pitting oedema bilaterally
Capillary refill – 5 seconds
Current weight 97kg.
Raised JVP
Output since midnight: 200ml; Input since midnight: approx 1672 mL (oral and IV)

Abdominal assessment
Abdomen soft and non-tender.
Bowel sounds present.

Respiratory assessment
Bibasilar posterior crackles
Increased work of breathing
Patient producing pink-tinged frothy sputum

 

10 Multi and Multiple Choice questions and 2 written answer questions

1. Clive’s myocardial infarction caused the death of areas of his cardiac tissue. Which of the following is the mechanism of cell injury?
2. a) Injury from biological agents
3. b) Ischaemia
4. c) Hypoxia
5. d) Necrosis

Ans: Necrosis

2. Clive’s myocardial infarction caused the death of areas of his cardiac tissue. Which of the following is the mechanism of cell death?
3. a) Apoptosis
4. b) Hypoxia
5. c) Necrosis
6. d) Ischaemia

 

Ans: Apoptosis

 

3. Clive suffered an acute myocardial infarction two years ago. Which of the following can be a consequence of this?
4. a) Cardiogenic shock
5. b) Stable angina
6. c) Hypertension
7. d) Paraesthesia

 

Ans: Cardiogenic shock

 

4. Which of the following are possible manifestations (signs or symptoms) of an acute myocardial infarction?

Select all that apply, leave blank those that do not apply. Marks lost by incorrect choices (right minus wrong)

1. Sudden dizziness
2. Sudden elevation in blood pressure

Bradycardia

3. Fatigue
4. Sudden leg weakness

Cold and pale skin

Paraesthesia in arms or legs

5. Tachypnoea

Diaphoresis

6. Dyspnoea
7. Crushing chest pain relieved at rest

Sudden drop in blood pressure

Chest pain that is not relieved by glyceryl trinitrate

Hot, flushed skin.

 

 

NB: All answers that apply are underlined and numbered above.

 

 

 

 

 

 

5. Clive has congestive heart failure. Which of the following are manifestations of this cardiac condition?

Select all that apply. Marks lost for incorrect answers (right minus wrong).

1. Pulmonary oedema

Peripheral oedema

Nocturia

1. Orthopnoea
2. Chest pain on exertion

Weight loss

1. Fatigue

Oliguria

1. Dyspnoea
2. Elevated JVP

Difficulty concentrating

1. Tachycardia
2. Bradycardia

Dry cough

 

 

NB: All answers that apply are underlined and numbered above.

 

 

 

 

 

 

 

6. According to the “HFrEF Management algorithm” by The National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand (CSANZ) guidelines for heart failure, in which should the therapeutic approaches to Congestive Heart Failure be introduced?
7. Beta-blocker
8. Mineralocorticoid receptor antagonist
9. Lifestyle modifications: exercise and reduction of salt intake
10. Diuretics
11. Ace inhibitors or arbs

– Arranged and numbered in of approach.

7. Clive’s peripheral oxygen saturation is 94% with oxygen supplementation. Which of the following is altering his oxygen homeostasis so that he needs the oxygen therapy?
8. a) Excessive ventilation of the alveoli due to tachypnoea
9. b) Oedema is interfering with the gas exchange
10. c) Pulmonary blood circulation is too fast due to tachycardia
11. d) Increased work of breathing causes ineffective alveolar ventilation

Ans: Excessive ventilation of the alveoli due to tachypnoea

8. Clive’s RR increased from 15-19 at 0600 to 24 breaths per minute in your last observation, but his oxygen saturation remained constant. What could be the reason for this?

Select all possible answers, leave the incorrect answers unselected. Marks lost for incorrect answers. (Right minus wrong).

1. His pulmonary circulation is less effective, causing the increase in RR.
2. The respiratory centres activate the sympathetic nervous system, increasing the RR.

His pulmonary oedema has worsened.

1. His brain is receiving less oxygenated blood and is compensating by increasing RR.

His SpO2 levels have dropped, not reflected in the oxygen saturation.

1. He is hypercapnic or becoming hypercapnic, which stimulates the increase in RR.

The gas exchange is less efficient and the increase in blood CO2.

His anxiety due to disorientation is activating the sympathetic nervous system.

 

NB: All answers that apply are underlined and numbered above.

 

9. Clive was prescribed with Spironolactone 25mg for the management of his congestive heart failure. Which of the following can be achieved by taking this drug?

Select all that apply, leave blank all that do not apply. Marks lost for incorrect answers. (Right minus wrong).

Reduced blood return to the heart

1. Inhibition of aldosterone action

Peripheral vasodilation

1. Oliguria

Coronary artery vasodilation

1. Decreased mean arterial blood pressure

Increased strength of cardiac muscle contraction

Reduced heart rate

1. Decreased sodium reabsorption in the kidneys

Reduction of sympathetic nervous system activity

Reduced formation of angiotensin II

1. Decreased cardiac output

 

 

 

NB: All answers that apply are underlined and numbered above.

 

 

 

 

 

 

 

10. Clive’s medication was augmented by adding furosemide for the management of this worsening of his congestive heart failure. Which of the following can be achieved by taking this drug?

Select all that apply, leave blank all that do not apply. Marks lost for incorrect answers. (Right minus wrong)

Suppression of aldosterone action

1. Reduced formation of angiotensin II

Reduced heart rate

1. Blockage of angiotensin receptors

Reduction of chloride reabsorption in the kidneys

Decreased cardiac output

1. Reduction of pitting oedema

Increased diuresis

1. Peripheral vasodilation
2. Reduction of sympathetic nervous system activity
3. Coronary artery vasodilation

Decreased sodium reabsorption in the kidneys

1. Decreases mean arterial blood pressure
2. Reduction to pulmonary oedema

 

 

 

NB: All answers that apply are underlined and numbered above.

 

11.

Explain the pathophysiological mechanisms through which Mr Jenkin’s congestive heart failure is leading to the current symptom of being Short of Breath on exertion.

Word limit: 200 words excluding in-text references. Use the School of Nursing guidelines for UTas Harvard referencing. These can be found in the “Assessment help and resources” section on MyLO

Abnormal pressure and cardiovascular overload, loosing muscles, muscular diseases, and peripheral demands like high output failure are among the causative agents of congestive heart failure. During congestive heart failure, heart muscles contract resulting to heart failure (Parmley 1985). This failure is characterized by lower cardiac output which results to the hearts inefficiency of meeting peripheral body demands. This is as a result of less oxygenated blood pumped by the heart to the body due to alteration of left ventricle (LV) hence affecting its performance.

Mr. Jenkin’s heart failure which resulted to his heart failure and shortness of breath could have resulted from several alterations of the LV. First, Mr Jenkin was probably experiencing low contractility of the internal muscles of his left ventricle which resulted to low blood pumping rate, hence shortness of breath at exertion. Similarly, there was an increase in the pressure of filling the right artery which resulted to pulmonary congestion. Increasing afterload even at lower blood pressure resulting to low cardiac output. These affect the general heartbeat rate as a mechanism of substituting for the general myocardial oxygen supply and demand imbalance (W 2021). This imbalance is responsible for heart failure and shortness of breath on exertion, and may be fatal in some instances.

12. Referring to specific Australian guidelines for the management of heart failure, explain why Clive has been prescribed with Ramipril, Spironolactone and Carvedilol.

Word limit: 200 words excluding in-text references. Use the School of Nursing guidelines for UTas Harvard referencing. These can be found in the “Assessment help and resources” section on MyLO.

The Cardiac society of Australia and Newzealand in collaboration The National Heart Foundation of Australia in collaboration with, defined heart failure (HF), as a complexity whose signs and manifestations can occur either at exertion or at rest (Atherton et al. 2018)¹. The latter provides heart failure diagnosis based on two distinct categories of reduced ejection fraction heart failure (HFrEF) and preserved ejection heart failure (HFpEF).

Ramipril is an ACE inhibitor. The guidelines provided by the Australian heart failure management recommends ACE inhibitors for patients with HFrEF conditions with an exception for contradiction or provision of intolerable ACE inhibitors to decrease mortality and hospitalisation (Atherton et al. 2018)². Ramipril was intended to reduce Clive’s blood pressure and prevent other heart diseases.

Spironolactone is a diuretic drug. Diuretic drugs are strong grade drug whose use has low supportive evidence by the Australian heat failure management guidelines. It is used for patients with Heart Failure clinical symptoms. Spironolactone was prescribed to help ease Clive’s congestion signs by managing his congestion and improve his symptoms.

Carvedilol is an alpha and betta blocker. Patients with HFrEF are recommended with Carvedilol when they are proven to have minimal or no congestions when examined. Carvedilol would help to decrease Clive’s mortality and hospitalization.

 

References

1. Atherton, JJ, Sindone, A, De Pasquale, CG, Driscoll, A, MacDonald, PS, Hopper, I, Kistler,

P, Briffa, TG, Wong, J, Abhayaratna, WP, Thomas, L, Audehm, R, Newton, PJ, OˈLoughlin, J, Connell, C & Branagan, M 2018, ‘National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the management of heart failure 2018’, Medical Journal of Australia, vol. 209, no. 8, pp. 363–369, viewed 12 January 2021, <https://www.mja.com.au/journal/2018/209/8/national-heart-foundation-australia-and-cardiac-society-australia-and-new-0>.

2. ‌ Atherton, JJ, Sindone, A, De Pasquale, CG, Driscoll, A, MacDonald, PS, Hopper, I

,Kistler, PM, Briffa, T, Wong, J, Abhayaratna, W, Thomas, L, Audehm, R, Newton, P, O’Loughlin, J, Branagan, M & Connell, C 2018, ‘National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Guidelines for the Prevention, Detection, and Management of Heart Failure in Australia 2018’, Heart, Lung and Circulation, vol. 27, no. 10, pp. 1123–1208, viewed 12 January 2021, <https://www.heartlungcirc.org/article/S1443-9506(18)31777-3/fulltext#secsect0245>.

Parmley, WW 1985, ‘Pathophysiology of congestive heart failure’, The American Journal of Cardiology, vol. 56, no. 2, pp. A7–A11, viewed 12 January 2021, <https://pubmed.ncbi.nlm.nih.gov/4014051/>.

W, R 2021, ‘[Pathophysiologic and diagnostic aspects of heart failure]’, Herz, vol. 15, Herz, no. 3, viewed 12 January 2021, <https://pubmed.ncbi.nlm.nih.gov/2198215/>.

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