Coronary Artery Disease

Coronary Artery Disease

10/31/2005

This paper will serve as a case study for the condition known as coronary artery disease (CAD). CAD occurs when the coronary arteries become hardened and narrowed; this is due to the buildup of plaque on the inner lining of the arteries. Blood flow to the heart is reduced as plaque narrows the coronary arteries, thereby decreasing the oxygen supply to the heart muscle. This loss of oxygen in the blood can lead to ischemia and later, myocardial infarction. The patient in this case is a 63 year old male with CAD that led to a myocardial infarction in April of 2003.

In speaking with the patient about his condition, a series of questions regarding the meaning of the illness to him, his family, and how he dealt with it were asked. The patient said he felt like he, "dodged a bullet with that heart attack, and to tell you the truth, I'm just happy to be alive." In April of 2003 it was found that his coronary arteries were severely obstructed and that led to the myocardial infarction. In addition to feeling like he was lucky to be alive, the patient voiced the need to enjoy everyday. The patient's wife had a more severe reaction to the incident. She became very involved in what he ate, his medications, and exercise regimen. The disease had most of its impact on the patient for the first year after he had the heart attack. Reduction in salt intake, dropping weight, and keeping an exercise program were all steps he took to prevent further damage to his arteries. However, after the first year he started to gain weight, add salt to his food, and quit his exercise program.

The course of the illness has seemed to slow down. Originally, the patient's blood pressure was 180/130 and now is 110/70. High-density lipoprotein (HDL) levels have increased, while low-density lipoprotein (LDL) levels have drastically decreased. The infarction has left the patient winded under physical stress, but the patient notes that he can still do the things he used to do, but just needs to take frequent naps. To keep momentum behind these declining factors, the patient is still receiving support from his wife. Although, the patient has slipped in terms of a strict diet and exercise plan, his wife continues to make sure his diet is reduced in fat and that he has some form of exercise several days a week.

Overall, familial support is given to the patient, but the impetus of improvement still lies with the patient. The patient's wife and family know what preventative methods need to be taken, and continue to give him support to break old habits and start new ones.

CAD, as mentioned previously, occurs when the arteries that supply blood to the coronary arteries become hardened and narrowed. This is due to atherosclerosis, the most common cause of coronary artery obstruction. This arterial plaque can be classified a couple of ways, hard and stable, or soft and unstable. Hard plaque causes the arterial walls to thicken and harden. This condition is associated more with angina than with a heart attack, but heart attacks frequently occur with hard plaque. Soft plaque is more likely to break open or apart and cause blood clots. This can lead to infarction.

There are several factors that lead to the development of CAD. The first is dyslipidemia. Increased levels of LDLs have been shown to result in dysfunction of the endothelial cells and increased oxidation of macrophages. Increased very low-density lipoprotein (VLDL) levels are a risk factor for CAD in people who have diabetes, middle-aged men, and in people with other lipoprotein abnormalities. Contrarily, high HDL levels are thought to be important in preventing atherosclerosis because they function to bring excess cholesterol from the tissues to the liver where it can be metabolized.

Cigarette smoking is a major factor in developing CAD. Even though the mechanisms by which smoking causes atherosclerosis are uncertain, studies indicate that 30% of the annual mortality from CAD can be traced to smoking. Cigarette smoking has been shown to cause endothelial destruction and reduce the oxygen content of arterial blood.

Hypertension is also a developing factor for CAD. It contributes to injury of the endothelial cells and cause myocardial demand for coronary flow because of myocardial hypertrophy. Other factors include diabetes mellitus, alcohol, stress, sedentary lifestyle, genetic predisposition, and obesity.

Parallels can be seen with classic predisposing factors and the factors that accelerated CAD in the patient. He was a middle-aged man, obese, a high-stress individual, and was a prolific cigarette smoker for more than 35 years of his life. The actual arterial blockage for the patient was not noticed until he had a heart attack in 2003. When he was in the hospital, an angiogram was performed and a blockage to his left anterior descending artery was noticed. The blockage showed that almost no blood was getting to the anterior portion of the heart. After an angioplasty was performed, a new angiogram was done and the amount of blockage was decreased substantially.

Many treatments and preventative measures can be taken to monitor and suppress CAD. Medications, surgical procedures, labs, lifestyle changes, and patient teaching are all factors in helping the patient overcome this disease.

Medications for the treatment and prevention of CAD are varied. Some medications decrease the workload on the heart and provide symptomatic relief, while others decrease the chance of having a heart attack or sudden death, and prevent or delay the need for angioplasty or a coronary artery bypass graft (CABG). Some common medications used to treat CAD are: Cholesterol-lowering meds, anticoagulants, antiplatelets, ACE inhibitors, Beta-blockers, calcium channel blockers, Glycoprotein IIb-IIIa inhibitors, nitroglycerin, and thrombolytics. These medications are all used for a variety of purposes, from pain management to lowering blood pressure. Anticoagulants

prevent arterial clots from forming. Antiplatelet meds prevent clots from forming in the arteries and blocking blood flow. ACE inhibitors lower blood pressure and reduce myocardial strain. Beta-blockers serve to lower the heart rate and blood pressure, with the overall effect of decreasing heart workload. Calcium channel blockers relax