MDSC 3311 PBL 1

Problem 1 Precordial Pain and Diaphoresis

VR is a 56-year-old East Indian male who works as an Assistant Manager at a tobacco company.
He presented to his primary care physician with a history of 2 episodes of chest pain while
climbing stairs last week. Each lasted for about 10 minutes and resolved with rest. After initial
inquiry and examination, his doctor ruled out non-cardiac causes of chest pain and performed an
ECG, which was normal. The doctor diagnosed him as having Class II Angina Pectoris. The
doctor identified the risk factors and advised the patient to control risk factors and to undergo
Stress test and prescribed Anti-anginal agents and ACE inhibitor. VR was promoted to the
rank of Manager and was transferred to Guyana and could not be followed up.
Four years later, while on vacation in Trinidad, he was rushed to the emergency service at Port of
Spain General Hospital for sudden onset of substernal chest pain associated with dyspnoea and
diaphoresis, which began at around 4.00 am. The pain radiated to his left arm and neck.
He smoked 20 cigarettes (one pack) per day for more than 15 years and has been consuming
alcohol in moderate amounts. His father had died suddenly at the age of 56, of heart-related
illness. There is no family history of diabetes mellitus.
Physical examination and investigations
Patient was anxious and in mild respiratory distress. His height was
1.68m and weight 84kg. His mucus membranes were pink and sclera,
anicteric. There was no jugular venous distension. Pulse=90/min. Heart sounds revealed soft S4
and lungs had basal rales. BP =140/90 mm Hg. Other organ systems examination was
unremarkable.
ECG showed evidence of an antero-septal acute STEMI. Lab investigations included a
complete blood count, electrolytes, BUN, BNP and cardiac enzymes. His lipid profile revealed
Total Cholesterol = 220 mg/dL, LDL= 130, HDL= 32. Coagulation panel and creatinine were
normal. Chest X-ray (portable) showed cardiomegaly.
The attending doctors quickly initiated treatment and his symptoms improved but developed
right bundle branch block (RBBB) and congestive cardiac failure. Anti-arrhythmic agents
and drugs for cardiac failure were added to the treatment protocol. He was discharged two weeks
later advising him about management of his condition.

Definitions:
Angina pectoris-Angina pectoris is a clinical syndrome that occurs when low blood flow to the
heart muscle (myocardial ischemia) limits delivery of oxygen. It is usually felt as discomfort,
pressure or tightening in the chest that is sometimes accompanied by pain in the left arm,
shoulders, or jaw.
Class II angina pectoris- refers to angina caused by more prolonged or more rigorous activity
than usual
Stress test-a test of cardiovascular capacity made by monitoring the heart rate during a period
of increasingly strenuous exercise.
Anti-anginal agents-drugs used to treat angina pectoris including nitrates, calcium channel
blockers and beta blockers
ACE inhibitior- An angiotensin-converting-enzyme inhibitor is a pharmaceutical drug used
primarily for the treatment of hypertension and congestive heart failure.
Diaphoresis-sweating, especially to an unusual degree as a symptom of disease or a side effect
of a drug
Jugular venous distension-JVD is a sign of increased central venous pressure (CVP).
Central Venous Pressure(CVP)- a measurement of the pressure inside the vena cava. CVP
indicates how much blood is flowing back into your heart and how well your heart can move that
blood into your lungs and the rest of your body.
Basal rales- abnormal lung sounds characterized by discontinuous clicking or rattling sounds
STEMI-ST-segment elevation myocardial infarction. It is one type of heart attack that can be
defined as a development of full thickness cardiac muscle damage resulting from an acute
interruption of blood supply to a part of the heart and can be demonstrated by ECG
(electrocardiography) change of ST-segment elevation.
Antero-septal acute STEMI- develops when anteroseptal wall (area between the left and right
ventricles) is damaged due to occlusion of septal branches of left anterior descending artery
(LAD). ECG features are ST-segment elevation in lead V1 V4with reciprocal ST-segment
depression in inferior leads (II, III and aVF)
BUN-Blood urea nitrogen (BUN) is a medical test that measures the amount of urea nitrogen
found in blood. The liver produces urea in the urea cycle as a waste product of
the digestion of protein. Normal human adult blood should contain between 6 and 20 mg of urea
nitrogen per 100 ml (620 mg/dL) of blood.
BNP-Brain natriuretic peptide (BNP) test is a blood test that measures levels of a protein called
BPN that is made by your heart and blood vessels. BNP levels are higher than normal when you
have heart failure.
Coagulation panel-A variety of tests that identifies coagulation defects, based on time required
for blood to clot; the CP includes prothrombin time, activated partial thromboplastic time,
platelet count, bleeding time
Cardiomegaly-abnormal enlargement of the heart
Right bundle branch block (RBBB)- A right bundle branch block (RBBB) is a heart block in
the electrical conduction system. During a right bundle branch block, the right ventricle is not
directly activated by impulses travelling through the right bundle branch. The left ventricle
however, is still normally activated by the leftbundle branch.
Congestive cardiac failure-occurs when the heart is unable to pump sufficiently to maintain
blood flow to meet the body's needs. Signs and symptoms commonly include shortness of breath,
excessive tiredness, and leg swelling.
Anti-arrhythmic agents-Antiarrhythmics are drugs that are used to treat abnormal heart
rhythms resulting from irregular electrical activity of the heart.

Issues:
1. What is the correlation between Vr's history of chest pain and his age and occupation?
2. Why did the doctor rule out non-cardiac causes of chest pain?
3. What is the significance of Vr having a normal ECG?
4. What allowed the doctor to diagnose Vr as having class II angina pectoris?
5. Why did the doctor advise the patient to control risk factors?
6. Why did the doctor advise the patient to undergo a stress test?
7. Why did the doctor prescribe anti-anginal agents and ACE inhibitor?
8. What is the consequence of Vr not being followed up by the doctor after his transfer to
Guyana?
9. What could have caused Vrs sudden onset of substernal chest pain associated with
dyspnoea and diaphoresis with the pain radiating to his left arm and neck?
10. What is the signifance of Vrs social history of cigarettes and alcohol?
11. What is the significance of the cause of the Vrs fathers death?
12. What is the significance of Vr having no family history of diabetes mellitus?
13. What is the significance of anxiety and mild respiratory distress?
14. What is the significance of pink mucous membranes and anicteric sclera?
15. What is the significance of no jugular venous distension?
16. What is significance of the soft S4 heart sounds and basal rales in the lungs?
17. What is the significance of antero-septal acute STEMI on Vrs ECG?
18. Why were tests done including the CBC, electrolytes, BUN, BNP and cardiac enzymes?
19. What ist he significance of normal coagulation panel and creatinine?
20. What is the significance of cardiomegaly?
21. What could have caused Vr to develop RBBB and congestive cardiac failure on
treatment?
22. Why were anti-arrhythmic agents and drugs for cardiac failure added to the treatment
protocol?

Hypotheses:
1.Vrs occupation and age put him at higher risk of chest pain.
2.This was ruled out since Vrs chest pains were resolved with rest.
3. A normal ECG indicates that Vrs chest pains only occur when he is performing a level of
activity.
4. This was diagnosed as Vrs chest pains only occurred during prolonged or more than
normal physical activity, which are the features of class II angina pectoris.
5. This was advised to Vr since putting himself at further risk could cause his condition to
worsen.
6. This was advised to allow the doctor to monitor Vrs heart rate during exercise, which is
particularly important in light of his class II angina pectoris.
7. ACE inhibitors and anti-anginal drugs help to reduce blood pressure and heart rate which
would jmake Vrs class II angina pectoris more mild.
8. This would prevent proper treatment of Vr since he would not be monitored to assess the
effectiveness of his treatment and if he is following his treatment correctly.
9.A myocardial infarction could have caused Vrs symptoms.
10.Vrs social history placed him at higher risk of cardiac complications.
11. Vrs father suffering from heart-related illness places him at higher risk of suffering from
the same illnesses due to heredity.
12. This means that Vr has a decreased risk of sufferring from diabetes mellitus.
13.Anxiety and respiratory distress indicates respiratory failure which can be caused by
damage to the heart or lungs.
14. This indicates normal vital signs and no jaundice and no high cholesterol levels(corneal
arcus).
15. This means that CVP is normal so the heart is pumping blood to the lungs normally,
16.A soft S4 heart sound is a sign of diastolic heart failure or active ischaemia. Basal rales
indicate a respiratory disease during inhalation.
17. This indicates vascular occlusion of septal branches of the left anterior descending artery
of the heart.
18.These were performed to monitor the levels of the components of Vrs blood and to check
for abnormalities.
19. Normal coagulation panel indicates no coagulation defects and normal creatinine levels
indicate normal kidney function.
20. Cardiomegaly can result from high blood pressure, coronary artery disease, pulmonary
hypertension, diabetes, kidney disease and other possible causes.
21.A pulmonary embolism could have occurred during treatment resulting in RBBB and
congestive cardiac failure.
22. These were added to help Vr control his RBBB and congestive cardiac failure.
Objectives:
Discuss the pathophysiology of angina pectoris and its classes
Discuss the cardiac and non-cardiac causes of chest pain
Discuss the risk factors of class II angina pectoris
Discuss the stress test and its importance with respect to class II angina pectoris
State the drugs used for the treatment of angina pectoris and describe their mechanisms of
action and side effects.
Discuss the management of the patient with class II angina pectoris including reasons
Discuss the pathophysiology of myocardial infarction
Discuss the pathogenesis of myocardial infarction along with its causes
Explain the biochemical markers used to diagnose myocardial infarction
Discuss the procedure in a physical examination of a myocardial infarction patient and
the clinical importance of all findings
Discuss the causes of right bundle branch block (RBBB)
Dicuss the causes of congestive cardiac failure
Discuss the management of a myocardial infarction patient including drugs used