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Course # 33223 • Women and Heart Disease

CASE STUDY 1

Read through the following clinical vignettes and take time to review each woman's cardiovascular risk factor profile. Then, refer to the questions at the end of the case study to analyze each female patient's current health status.

  • Patient S is a white woman, 43 years of age, and mother of three small children. She has a long-standing history of significant obesity with little success in dieting over the years. At 5'3", she is obese, weighing 220 pounds. Her fat distribution is "apple-shaped" and consequently, her waist-hip ratio is more than the 0.8 normal range. In addition, Patient S lives a fairly sedentary lifestyle and does not have a regular exercise program. Her dietary habits do not take into account basic recommendations for cardiac nutrition.

  • Patient J is 55 years of age and teaches high school English. Her coronary risk factor profile includes a 30-pack-year history of cigarette smoking and altered lipid levels. Her HDL is only 35 mg/dL and her LDL is 145 mg/dL. Patient J has tried with little success to control her cholesterol with diet. Recently, she began taking gemfibrozil as prescribed by her family physician, but has not followed his recommendation to quit smoking and enroll in a smoking cessation program at a local hospital. Rather, she continues to smoke one pack of cigarettes per day.

  • Patient V is a woman, 47 years of age, who has a family history of heart disease. Although she denies ever experiencing cardiac symptoms, her brother suffered a nonfatal MI at 46 years of age and her father had an MI at 53 years of age. Both of these cardiac events were medically managed. However, her father's disease did progress to the point that he underwent CABG surgery five years ago. He had three coronary artery lesions bypassed. In addition to her family history, Patient V is approximately 30 pounds overweight and does not exercise on a regular basis. She drinks approximately two to three glasses of red wine per day and has never smoked.

  • Patient D is 67 years of age and lives in an assisted living retirement community. An insulin-dependent diabetic since adolescence, Patient D is unable to care for herself due to the effects of the diabetes on her eyesight, as well as the development of peripheral neuropathies. In addition to the diabetes, Patient D continues to smoke. By now, she has a 40-pack-year history of smoking.

  • Patient F is an African American woman, 36 years of age, with a history of mild hypertension. Her blood pressure has been fairly well controlled on an ACE inhibitor over the past two years. Patient F eats a well-balanced, nutritious diet, exercises three to five times a week, and does not have a history of smoking or alcohol use. However, she does exhibit many of the characteristics of the Type A behavior pattern, such as excessive competitiveness, being harried, and rushing to complete more and more tasks in an ever-shrinking period of time. In addition to these characteristics, she exhibits a somewhat cynical or negative outlook with occasional expression of hostile or angry thoughts and feelings.

In analyzing these clinical vignettes, consider the following questions:

  1. Which of these women is at greatest risk for heart disease?

  2. Who is at least risk?

  3. What recommendations would you make in counseling each patient regarding her cardiovascular health?

Case Study 1 Analyses

1. Which of these women is at greatest risk for heart disease?

All five of these women have risk factors for heart disease. However, Patients J and D possess three of the most significant cardiovascular risk factors: cigarette smoking, diabetes, and hyperlipidemia. Therefore, based on the data available in the vignettes, Patients J and D are at greatest risk for coronary heart disease. If further information was available about each woman's cardiac risk factor profiles, we might be able to differentiate even further to determine which of these two women is at greater risk.

2. Who is at least risk?

Patient F appears be in the best cardiovascular state among the group. Her mild hypertension is well controlled; she is not overweight, eats a sensible diet, and sees that she gets some form of aerobic exercise at least three times a week.

3. What specific recommendations would you make in counseling each woman about her cardiovascular health?

Patient S

Counseling recommendations for Patient S would primarily focus on cardiac nutrition aspects and developing an exercise program for cardiovascular fitness. Because she is more than 30% overweight, she is at a tremendously increased risk of coronary heart disease due to the added stress on her heart and the changes that occur in lipid metabolism when fat is distributed in the abdominal versus gluteal region. Therefore, patient teaching should emphasize good nutrition and reading nutrition labels to manage caloric intake, as well as limiting intake of fat and cholesterol. In addition to changes in diet, Patient S should be counseled on incorporating some form of aerobic exercise, such as walking, three to five times a week to achieve cardiovascular fitness. The exercise will also have the added benefit of helping her modify her weight level.

Patient J

Two major concerns become evident in assessing Patient J's health status—her smoking history and her hyperlipidemia. Recommendations would focus on encouraging and motivating the patient to quit smoking, through the use of the nicotine patch or gum with the additional support of bupropion and/or a smoking cessation program to increase her chances of successfully quitting. These programs are essential because they teach the patient behavioral and psychologic techniques to utilize at various stages of the quitting process and help the person identify specific problem situations and how these can be realistically managed. Patient J's lipid profile should be closely monitored to determine the effectiveness of gemfibrozil in lowering her LDL levels. In addition, patient teaching should focus on the deleterious effects of smoking on lipid profiles, specifically HDL levels. Smoking tends to decrease levels of HDL, which could be used as another health information tidbit to motivate Patient J to quit smoking.

Patient V

Recommendations for cardiac health for Patient V would primarily focus on the alterable factors rather than her significant family history, which cannot be changed. As a result, patient teaching and counseling would be geared toward getting her weight into a more desirable range by paying attention to nutrition and getting some form of regular aerobic exercise. Patient V would also benefit from more health teaching regarding alcohol consumption. While a moderate intake of alcohol may be associated with positive antioxidant effects that can impart some protection against the development of heart disease, the key is moderation. One drink per day is the recommendation for alcohol consumption in women.

Patient D

In assessing Patient D's health history, her diabetes and smoking habit are big concerns. In terms of her diabetes, she is in need of strict control to prevent further progression and significant complications associated with the disease, such as coronary heart disease. Another major factor that would help prevent a major cardiac event is for her to quit smoking. Remember that many cardiovascular risk factors are synergistic. In other words, risk factors work together in increasing an individual's risk of developing coronary heart disease. Cigarette smoking and diabetes are both powerful independent risk factors for heart disease, and together, they significantly elevate the chances of developing the disease.

Patient F

Patient counseling recommendations for Patient F are twofold: continued control of her hypertension and stress management. Patient F and all of the women should be applauded regarding the positive habits they have incorporated into their lifestyle. In this patient's case, these positive aspects include attention to nutrition, aerobic exercise, and staying away from smoking or alcohol use. She does, however, need assistance with stress management. While her regular exercise program is most likely one avenue for her to deal with this stress, it obviously is not singly effective. In other words, additional stress management strategies could be added to her repertoire.

CASE STUDY 2

Patient M is a white woman, 75 years of age, who presented to her local emergency room with sudden complaints of chest pain. She described the pain as a severe substernal burning sensation that radiated across the chest to her shoulders bilaterally and then to the neck and jaw region. Although not brought on by exertion, the chest pain was associated with dyspnea, pallor, diaphoresis, nausea, and epigastric discomfort. Patient M had taken one nitroglycerin tablet with partial relief. When the chest pain recurred 10 to 15 minutes later, her family dialed 911 and the local emergency medical service responded. Once transported to the emergency room, her pain persisted. She received two additional doses of nitroglycerin and was placed on 2 L of oxygen per nasal cannula.

Following stabilization, she was admitted to a telemetry floor for further observation and medical management. Nursing assessment revealed the following cardiovascular risk factors: 50-pack-year history of cigarette smoking, hypertension, and mild-to-moderate obesity. As part of the medical workup, Patient M was scheduled for a cardiac catheterization the following day. The cardiac catheterization revealed an 80% blockage of the right coronary artery and the cardiologist recommended Patient M consider a PCI to open the coronary artery blockage.

The following day, Patient M underwent a PCI to the right coronary artery. The procedure was progressing uneventfully until she had an episode of bradycardia; her heart rate dropped to 38 beats per minute. The patient received a 0.5 mg dose of IV atropine, which was repeated in 10 minutes. Other than this episode, Patient M did not experience any other postprocedure complications, such as hypotension, or other technical-related problems.

The day after the PCI, Patient M was receiving her discharge instructions from her nurse when she began noticing a return of the dull epigastric pain. The pain did not appear to be related to her food intake because she was progressing on her diet. Later that day, as the pain persisted, Patient M had an ultrasound of her abdomen, which showed multiple walnut-sized gallstones. The gastroenterologist referred her to a general surgeon who recommended that she undergo a cholecystectomy for further relief of her gastrointestinal symptoms. The surgeon advised her of the risks and benefits of laparoscopic versus traditional surgery, and Patient M opted for the laparoscopic procedure. Four small incisions were made in her abdomen, and the cholecystectomy was performed without any complications. Three days postoperatively, she complained again of moderate-to-severe epigastric pain and became jaundiced. An endoscopic retrograde cholangiopancreatography revealed retained stones in the common bile duct, which were removed. Patient M subsequently recovered and was discharged home after a total of nine days in the hospital.

In analyzing this case study, consider the following questions:

  1. What coronary risk factors are present? What risk factors are negative?

  2. Is the patient's chest pain syndrome typical or atypical for women? Why or why not?

  3. What tests would you anticipate to be in the diagnostic workup of women experiencing angina?

  4. What nursing diagnoses would be appropriate for this patient during hospitalization? What special implications do these diagnoses have in women?

Case Study 2 Analyses

1. What coronary risk factors are present? What risk factors are negative?

The cardiovascular risk factors that are known for Patient M from the case study are her age, the fact that she has past menopause, her smoking history, and hypertension.

2. Is the patient's chest pain syndrome typical or atypical for women? Why or why not?

The chest pain syndrome experienced by Patient M is typical for women. She described the chest pain as a substernal burning sensation that radiated across her precordium to her shoulder region bilaterally and then to her neck and jaw. In addition, her chest pain was accompanied by dyspnea, diaphoresis, nausea, and epigastric distress, all of which may or may not be associated with anginal episodes in women. In contrast, chest pain in men often begins substernally and spreads across the left precordium down the left arm.

3. What tests would you anticipate to be in the diagnostic workup of women experiencing angina?

The diagnostic phase for women with angina often begins with a resting 12-lead EKG. This test is useful in women due to their higher proportion of silent or unrecognized infarctions. Conversely, the exercise EKG is not considered a good test in women due to high false-positive rates and other problems associated with women exercising at adequate intensity levels. Other noninvasive cardiac diagnostic tests might include the nuclear medicine stress test, ventriculogram, and exercise echocardiogram. Of these three tests, the exercise echocardiogram is the best test for women. It is associated with the highest accuracy rates and is especially sensitive to single vessel disease, which occurs more frequently in women than in men.

4. What nursing diagnoses would be appropriate for this patient during hospitalization? What special implications do these diagnoses have in women?

  • Decreased Cardiac Output: With the sudden onset of angina and need to undergo a PCI to open a blockage of the right coronary artery, Patient M is at risk for decreased cardiac output. Women should be taught to take angina seriously and to have it evaluated by a physician as soon as possible. This is especially critical in women because they have an unfavorable prognosis post-MI. After PCI, women also have higher mortality rates and, therefore, should be carefully assessed. Complications must be recognized early in their course so they can be corrected and managed successfully.

  • Pain: Patient M really has two etiologies of her pain: chest pain and epigastric discomfort referred from her biliary tract disease. It is important to recognize that angina is often more severe in women than men (and both stable and unstable angina are more frequent in women), and therefore, necessary pharmacologic therapy may be more intense. In women, angina is managed best by either nitrates or calcium channel blockers, although the dosage may not be the same as it is in men. Because women have been excluded from many clinical drug trials testing cardiac medications, the optimal dose of various medications to treat women is less well known. Further research is needed to guide this area of clinical practice.

  • Knowledge Deficit: Like any other patient undergoing diagnostic testing and an invasive cardiac procedure, not to mention the cholecystectomy, Patient M should be taught about various components of her illness and hospitalization. These components include her disease process, diagnostic tests, medications, risk factor modification, and the recovery process, with emphasis on the long-term positive outcomes associated with PCI in women. In addition, when teaching female cardiac patients, it is vital to search for patient teaching materials that discuss the unique concerns of women with heart disease.

CASE STUDY 3

Patient Y, a woman 76 years of age, was seen in the Women's Cardiac Center for a personalized health and risk factor assessment. Assessment findings included a heart rate of 84 beats per minute, blood pressure 172/68 mm Hg, height 5'5", and weight 171 pounds. Waist-hip ratio was 0.75, and skin fold calipers measured 42% body fat. Lipid profile included total cholesterol of 239 mg/dL, HDL 40 mg/dL, LDL 159 mg/dL, ratio 5.9 mg/dL, and triglycerides 248 mg/dL. Fasting glucose was 79 mg/dL. Past medical history included hiatal hernia, cholecystectomy, hypothyroidism, arthritis, insomnia, and a long-standing history of ankle edema. The patient also reported symptoms suspicious of sleep apnea.

Based on this assessment, cardiovascular risk factors were identified and the patient was instructed on risk factor modification. Four months later, she phoned the Women's Cardiac Center with complaints of anterior chest discomfort that radiated to her neck, jaw, and back and was accompanied by shortness of breath. She was referred to Cardiology and seen three days later.

The diagnostic workup included a 12-lead EKG and nuclear medicine stress test (thallium scan), followed by cardiac catheterization. She was not considered a candidate for the exercise EKG due to her advanced age and other comorbidities, specifically arthritis, which would limit her ability to exercise at adequate intensity levels. The 12-lead EKG revealed nonspecific T-wave changes in the inferior leads, and the nuclear medicine test was positive, suggestive of single-vessel disease of the left circumflex artery. Cardiac catheterization was then performed and showed triple vessel disease with significant left main disease. Her occlusions were 50% to 60% of the left main, 90% of the circumflex, and 60% of the right coronary artery. EF was estimated at 60%, indicating preserved left ventricular function. Based on these diagnostic findings, the patient was referred for cardiac surgery.

Two weeks later, Patient Y underwent CABG surgery with internal mammary grafting. During surgery, she required inotropic support with dobutamine and epinephrine and atrioventricular sequential pacing. An intra-aortic balloon pump (IABP) was also placed via the right femoral artery due to right heart failure. On the first postoperative day, the patient remained in the intensive care unit on the IABP and ventilator. Lab values showed a creatine phosphokinase of 3113 IU/L and creatine kinase isoenzyme MB of 169.4 IU/L. A bedside echocardiogram confirmed an inferior-posterior and right ventricular infarct.

The patient was transferred to the cardiac surgical stepdown unit on the third postoperative day, where she developed atrial fibrillation and was digitalized. Oxygen was administered at 5 L per nasal cannula and her ambulation was significantly limited. In addition, a bruit was noted in her right groin. An echo-Doppler revealed a two-chamber pseudoaneurysm, which was unsuccessfully compressed. On the sixth postoperative day, the patient went in and out of atrial fibrillation/flutter and converted to sinus rhythm on postoperative day 7. As a result, she was weaned from oxygen and progressed with independent ambulation. However, she remained hospitalized until postoperative day 12 for observation of her heart rhythm and right groin pseudoaneurysm.

Two days after discharge, the patient received a follow-up telephone call from the Cardiac Liaison Nurse to assess her condition. Patient Y stated she was "feeling pretty good," yet indicated some difficulty with incisional pain, anorexia, fluid loss, insomnia, and confusion about her medications. After recuperating at home, the patient enrolled in a phase II cardiac rehabilitation program. At this time, the patient reports no angina or chest discomfort. She is progressing in her exercise program and tolerating activity. Problems experienced since discharge include a urinary tract infection, depression, and increasing heart failure. Her furosemide dosage has been increased, and she has obtained good relief of her symptoms.

In analyzing this case study, consider the following questions:

  1. What coronary risk factors are present? What risk factors are negative?

  2. Is the patient's chest pain syndrome typical or atypical for women? Why or why not?

  3. What is the common picture of a woman's general health and cardiac status when referred for CABG surgery?

  4. What significance does this patient's perioperative MI have for her long-term prognosis?

  5. What nursing diagnoses would be appropriate for this patient during hospitalization? What special implications do these diagnoses have in women?

  6. Identify ways to assess both short- and long-term outcomes of women post-CABG surgery.

Case Study 3 Analyses

1. What coronary risk factors are present? What risk factors are negative?

Patient Y has the following cardiovascular risk factors:

  • Age: Older than 60 years of age

  • Positive family history: Both parents died from heart disease

  • Hypertension: 172/68 mm Hg

  • Hypercholesterolemia: Total cholesterol 239 mg/dL; HDL 40 mg/dL; LDL 159 mg/dL; ratio 5.9; triglycerides 248 mg/dL

  • Body composition: Percentage of body fat is 42%

  • Menopause: Received HRT for 20 years

  • Stress: Rated as a 5 on a 0 to 10 scale

The following cardiovascular risk factors are negative:

  • Personal history of cardiovascular or cerebrovascular disease

  • Diabetes

  • Smoking history

  • History of alcohol consumption

  • Sedentary lifestyle (Reports walking one mile per day)

2. Is the patient's chest pain syndrome typical or atypical for women? Why or why not?

As in the previous case study, Patient Y's chest pain syndrome is fairly typical for women. She experienced chest discomfort in the anterior region of her chest, which then radiated to her neck, jaw, and back. The chest pain was also accompanied by shortness of breath, which may or may not occur in women, just like other associated symptoms such as nausea, diaphoresis, or lightheadedness.

3. What is the common picture of a woman's general health and cardiac status when referred for CABG?

Like Patient Y, women who are referred for cardiac surgery tend to be older with more comorbidities or multiple health problems, including hypertension, hypothyroidism, questionable sleep apnea, arthritis, hiatal hernia, and sciatica. In terms of cardiac status, women tend to be referred more often for unstable angina, in comparison to men, who usually are referred on the basis of a positive exercise EKG. In addition, women tend to have a lower incidence of prior MI before surgery and, therefore, better EFs; fewer diseased arteries or more single vessel disease (50% have single-vessel disease versus 25% two-vessel and 25% three-vessel disease); and more left ventricular hypertrophy and mitral regurgitation.

4. What significance does the patient's perioperative MI have for her long-term prognosis?

Women who suffer an MI have a worse prognosis than men, which is why timely diagnosis with an appropriate workup and treatment is so important in women experiencing anginal symptoms. When women go on to infarct, they have a much greater chance of not surviving, both in the early postinfarct period as well as later on.

5. What nursing diagnoses would be appropriate for this patient during hospitalization? What special implications do these diagnoses have in women?

  • Decreased Cardiac Output: Patient Y was a woman with complaints of angina who underwent CABG surgery. During the surgical procedure, she suffered an inferior-posterior and right ventricular infarct. Despite the fact that her left ventricular EF was preserved at 60% post-MI, she should be carefully observed for early signs of heart failure, as well as any other complications during the postoperative period.

  • Pain: Again, prior to surgical intervention, Patient Y's angina should be carefully assessed and treated with nitrates or calcium channel blockers to prevent an acute MI, which would significantly impact her prognosis and long-term outcome. While postsurgical pain is most likely incisional, it is still important to assess for the return of angina, which could signal reocclusion of one of the bypass grafts.

  • Activity Intolerance: Patient Y is 76 years of age with multiple health problems, including arthritis. She will likely be slow to mobilize in the postoperative phase to begin with, which is compounded by the problems she developed with postoperative atrial fibrillation. After her ventricular rate was controlled and the pseudoaneurysm was addressed, her cardiac rehabilitation activity and exercise program was appropriately resumed.

  • Body Image Disturbance: This is a potential nursing diagnosis for Patient Y given her feelings of depression in the postdischarge phase. These feelings could be considered a normal part of recuperation and a reflection of perceived changes in body image due to the sternotomy and leg incisions. After being discharged home, she did complain of continued incisional pain that could be partially alleviated by wearing a supportive bra to decrease tension from the breasts.

  • Knowledge Deficit: As with Patient M in Case Study 2, Patient Y has a knowledge deficit regarding her cardiac disease and surgical procedure. Patient teaching for Patient Y should incorporate elements such as disease process, cardiac medications, activity restriction, caring for the surgical incision, risk factor modification, outpatient cardiac rehabilitation, and the recovery process. She would also benefit from gender-specific patient teaching aids, if available, so she could relate to the unique concerns and needs of women who have faced heart disease and cardiac surgery.

6. Identify ways to assess both short- and long-term outcomes of women post-CABG surgery.

Patient outcomes may be measured both during the hospitalization phase and during the postdischarge phase. During the hospitalization phase, examples of clinical outcomes to be assessed for a population of female cardiac patients include complication rates (e.g., perioperative MIs, dysrhythmias, pseudoaneurysms); length of stay (both intensive care unit and hospital length of stay); and readmissions (both intensive care units and hospital readmissions), along with the clinical reasons.

After the hospitalization phase, patient outcomes may be assessed again. Examples of outcomes to be measured in the early discharge phase include pain, appetite, wound healing (incisions in surgical patients), rest/sleep patterns, psychologic comfort, and exercise patterns. Teaching and learning outcomes are also important to assess, including whether the female cardiac patient understood her discharge instructions related to activity and exercise, cardiac medications, diet, and when to return to work. Quality of life becomes an important consideration for this population. Research suggests that women experience more days of restricted activity due to continuing cardiac symptomatology, such as recurring chest pain and dyspnea. Ability to return to work and previous hobbies and pastimes would be an important area to assess in this regard.

CASE STUDY 4

Patient A was a woman, 88 years of age, who lived in an assisted living retirement home. She had been a widow for 20 years, after losing her husband to long-term complications associated with diabetes. Until approximately seven years ago, Patient A had been in relatively good health with no major health problems, but she suffered a mild stroke at 81 years of age. At that time, she decided to quit her 50- to 60-year smoking habit. Other than her smoking history, she did not have any other significant cardiovascular risk factors.

After recuperating from her stroke, Patient A decided to leave her apartment and move into the assisted living facility where she would not only have some companionship but also receive assistance with meals and transportation to doctor's appointments and other activities. About six years after suffering the cerebrovascular accident, she had a bout of heart failure. She was admitted to the local hospital and received oxygen per nasal cannula, IV furosemide, and digoxin. After two weeks in the hospital, the patient was discharged home in apparently better condition. However, two days after returning home Patient A suffered a sudden cardiac death event at the breakfast table. Efforts at resuscitation were unsuccessful.

In analyzing this case study, consider the following questions:

  1. What coronary risk factors are present? What risk factors are negative?

  2. Is the patient's chest pain syndrome typical or atypical for women? Why or why not?

CASE STUDY 4

Case Study 4 Analyses

1. What coronary risk factors are present? What risk factors are negative?

Positive cardiovascular risk factors for Patient A include the nonalterable factors of age and menopause and the alterable factor of smoking history. The risk factors that were negative in her history include family history of cardiovascular disease, hypertension, hyperlipidemia, obesity, sedentary lifestyle, or Type A behavior pattern.

Is the patient's chest pain syndrome typical or atypical for women? Why or why not?

Patient A's cardiac event is atypical for women in terms of initial presentation of the disease process. MI and sudden cardiac death are more commonly a first manifestation of heart disease in men, while angina is the most common presenting scenario for women. Women tend to lag behind men in both the occurrence and incidence of heart disease, as well as sudden cardiac death events. In terms of Patient A's history, it is possible that she initially suffered an MI, which was not recognized, and went on to develop heart failure as a post-MI complication. This then explains her increased risk for earlier reinfarction and higher mortality.

CASE STUDY 5

Patient H, a white woman 60 years of age, suddenly began complaining of chest pain to her family one evening. The pain was substernal, spread down both arms bilaterally, and radiated to her neck and jaw region. Patient H also complained of shortness of breath, nausea, and diaphoresis. Never having witnessed these symptoms before, Patient H's husband and daughter transported her to the local emergency room.

When she arrived in the emergency room, immediate priorities focused on obtaining a brief yet comprehensive history of symptomatology and past medical problems, as well as instituting appropriate treatments. The health assessment revealed numerous cardiovascular risk factors. Of course, Patient H's increasing age is one nonalterable risk factor present. In addition, she has a significant family history of heart disease. Her mother and grandmother both suffered fatal heart attacks in their late 50s or early 60s. While Patient H does not have a history of smoking, she does have hypertension, hyperlipidemia, and diabetes. She is also obese, with a height of 5'2" and weight of 240 pounds, and does not report engaging in a regular exercise program.

In terms of supportive treatment, Patient H was placed on 3 L of supplemental oxygen per nasal cannula and given sublingual nitroglycerin. She rated her pain an 8 on a 0 to 10 scale and did not report an appreciable decrease in her pain level after the first nitroglycerin dose. A second sublingual dose was given, after which she obtained relief. In the diagnostic workup phase, Patient H had a 12-lead EKG that revealed signs of ischemia in leads II and III and a ventricular fibrillation. Serial cardiac enzymes were also drawn to rule out MI. Patient H was admitted to the coronary care unit (CCU) for treatment of an inferior MI.

Once transferred to the CCU, the patient was placed on the bedside monitor and a left radial arterial line and left subclavian Swan Ganz catheter were inserted for hemodynamic monitoring purposes. A bedside echocardiogram was also performed to assess left ventricular EF and overall function of the chambers of the heart. The exam revealed that left ventricular EF was not preserved, estimated at only about 40%. Positive inotropes were started to increase the contractility of the heart and improve cardiac output. Intravenous nitroglycerin that was started in the emergency room was continued to improve coronary perfusion and for afterload reduction. After two days, Patient H was transferred out of the CCU to the cardiology stepdown unit. Telemetry showed slight sinus bradycardia at a rate of 56 beats per minute without ectopy. Other vital signs included blood pressure 102/56 mm Hg and a respiratory rate of 26 breaths per minute. Patient H remained on supplemental oxygen at 2 L per nasal cannula.

Cardiac rehabilitation was initiated when Patient H was in the stepdown unit. Rehabilitation activities first focused on identifying her risk stratification level, from low to high on a continuum, to guide initial activity and further exercise prescriptions. Because the patient's left ventricular EF was approximately 40%, her risk stratification level was identified as moderate and she was instructed that her cardiac rehabilitation activity would entail ambulating three times a day, first with monitored assistance in the hallway, working eventually toward the goal of independent ambulation. Prior to her first ambulation, Patient H's nurse took orthostatic blood pressure readings with the following results: lying 120/68 mm Hg; sitting 116/64 mm Hg; and standing 112/62 mm Hg. Heart rate pre-exercise was 58 beats per minute. As a result of these data, Patient H was assisted into the hallway for monitored ambulation. After walking for approximately two minutes, her heart rhythm converted from sinus bradycardia into a fast atrial fibrillation, with a ventricular rate of 180 beats per minute. Her blood pressure was 102/56 mm Hg. The patient was assisted back to bed, and a cardiology consult was requested.

The consulting cardiologist ordered a diltiazem drip. After her ventricular rate was under control, the patient was digitalized with 1 mg of digoxin followed by a maintenance dose of 0.125 mg IV. Other cardiac medications added to the regime included a beta blocker, furosemide, and potassium.

On the day of discharge, Patient H's family was present for discharge teaching. Her nurse explained the list of medications, including the dose and frequency, as well as her activity limitations. Patient H was instructed not to drive a car for two weeks and to increase her walking each day by one minute until she arrived at the goal of approximately 30 to 45 minutes at least three times a week. In addition, Patient H was informed about the nearest outpatient cardiac rehabilitation program. It was explained to her that the primary benefits of attending an outpatient program would be that the staff would assist her in developing an activity and exercise program individualized to her needs and physical capabilities. In addition, they would teach her and her family other components of heart healthy living, such as cardiac nutrition, managing diabetes, and stress.

After discharge, the patient did enroll in an outpatient cardiac rehabilitation program and had attended three sessions when she began developing symptoms of heart failure, including orthopnea, shortness of breath, and weight gain. On physical examination, crackles were auscultated bibasilarly and dependent pitting edema was present in her ankles bilaterally. On being seen in the heart failure clinic, she was restarted on a diuretic, furosemide, and an ACE inhibitor and her digoxin was kept at the same dosage.

In analyzing this case study, consider the following questions:

  1. What coronary risk factors are present? What risk factors are negative?

  2. Is the patient's chest pain syndrome typical or atypical for women? Why or why not?

  3. What nursing diagnoses would be appropriate for this patient during hospitalization? What special implications do these diagnoses have in women?

  4. What special implications exist with regard to dosing cardiac medications in women?

  5. Describe the common response of women with heart disease to activity.

  6. What factors influence women's involvement in cardiac rehabilitation programs?

CASE STUDY 5

Case Study 5 Analyses

1. What coronary risk factors are present? What risk factors are negative?

Patient H has the following cardiovascular risk factors:

  • Age: 60 years of age

  • Positive family history: Mother and grandmother both died prematurely from an MI

  • Hypertension

  • Hyperlipidemia

  • Diabetes

  • Obesity: Weight 240 pounds; height 5'2"

  • Sedentary lifestyle

  • Postmenopausal

The following cardiovascular risk factors are negative:

  • Personal history of cardiovascular or cerebrovascular disease

  • Smoking history

  • History of alcohol consumption

  • Perceived stress

2. Is the patient's chest pain syndrome typical or atypical for women? Why or why not?

Patient H's chest pain was located substernally and radiated down both arms and to her neck and jaw. In addition, she was short of breath, diaphoretic, and nauseated. This clinical picture is fairly typical in women. Unlike the usual presentation in men, women may complain of no chest pain or chest pain that does or does not radiate. The pain may also be accompanied by other cardiac symptoms such as diaphoresis, dyspnea, or lightheadedness, but not necessarily so; these symptoms may be altogether absent.

3. What nursing diagnoses would be appropriate for this patient during hospitalization? What special implications do these diagnoses have in women?

Nursing diagnoses that would apply in this case study include decreased cardiac output, pain, activity intolerance, and knowledge deficit. The nursing implications that these diagnoses have in women have been discussed in previous case studies. In women who have suffered an MI, it is important to assess for other health problems or conditions that could impact their recovery because their morbidity and mortality rates are already higher than women with angina or those who have undergone a revascularization procedure.

4. What special implications exist with regard to dosing cardiac medications in women?

Research to date has not generally included women in clinical trials on the efficacy of cardiac medications. The optimal dose of these medications in women requires further study because, for the most part, they were tested on men. It may be that women need less, more, or the same dose as men. Further research including women is needed to determine the therapeutic dosage ranges for various cardiac medications, such as nitrates, beta blockers, or calcium channel blockers.

5. Describe the common response to activity of women with heart disease.

In general, women with heart disease tend to be older than their male counterparts. As a result, women presenting with cardiac problems may also have other significant comorbidities such as diabetes, hypertension, and arthritis, which may slow their activity progression. Therefore, during the acute phase, it is essential to involve either physical therapy and/or cardiac rehabilitation to begin mobilizing the patient and progressing with activity as appropriate to the patient's condition.

6. What factors influence women's involvement in cardiac rehabilitation programs?

Many factors have been studied regarding women's participation in formal outpatient cardiac rehabilitation programs. Some of the most common reasons women give for decreased attendance include family commitments, financial concerns, and medical problems, such as increasing angina and/or other cardiac symptoms.

CASE STUDY 6

The following vignettes describe women with cardiac symptomatology who received either medical or surgical treatment. Read through these vignettes and analyze them using the questions that are presented at the end of the case studies.

  • Patient R, a black woman 52 years of age, recently underwent a CABG procedure. Cardiac catheterization revealed three-vessel disease. As a result, she had bypasses to her right coronary artery, left circumflex artery, and obtuse marginal artery.

  • Patient B is a white woman, 65 years of age, with a long-standing history of stable angina. She has been medically managed for the past several months on nitrates (sublingual nitroglycerin) and an ACE inhibitor.

  • Patient L is 45 years of age. She experienced a sudden onset of chest and arm pain while driving to a family affair with her husband. Because the pain did not subside, her husband drove her directly to the local emergency room, where she was evaluated and underwent several diagnostic tests, including a 12-lead EKG, serial cardiac enzymes, and a dipyridamole echocardiogram. The 12-lead EKG and cardiac enzyme elevations suggested an evolving MI. As a result, Patient L was treated with thrombolytic therapy in the emergency room, then admitted to the CCU for further treatment and observation.

  • Patient E, an Asian American woman 52 years of age, had been experiencing episodes of pain that spread across her chest and occasionally radiated down one or both arms and/or to her jaw region. Over the last week or so, the chest pain episodes increased in frequency to the point she thought she should have a medical evaluation. Patient E saw a cardiologist, who suggested the patient undergo a cardiac catheterization. The procedure revealed a 60% lesion of the right coronary artery that the cardiologist believed could be treated successfully with angioplasty.

In analyzing this case study, consider the following questions:

  1. Based on the information, which woman has the best prognosis? The worst prognosis? Why?

  2. What are some of the complications associated with each of these medical and surgical therapies?

CASE STUDY 6

Case Study 6 Analyses

1. Based on the information, which woman has the best prognosis? The worst prognosis? Why?

Patient B has the best prognosis. She has a long-standing history of stable angina that has been adequately managed with nitrates and an ACE inhibitor. Women with angina have a better prognosis than those who suffer an MI, one of the main reasons why it is so important to accurately assess a woman's cardiovascular risk factors and work on modifying those areas possible to prevent an MI from ever happening. After a woman has an MI, the mortality rates are significantly higher.

On the other hand, Patient R and Patient L have the worst prognoses of the women presented in this vignette. Women who undergo CABG surgery have double the perioperative mortality rate of men and also fare poorer in the early postoperative period, generally complaining of more angina, dyspnea, and reduced mobility. These findings may be due to the fact that women tend to be older at the time of surgery, have more advanced disease, and significant comorbidities. However, five- and 10-year survival rates between men and women are comparable.

2. What are some of the complications associated with each of these medical and surgical therapies?

  • Medical Management: A possible complication or adverse effect associated with medical management focuses on the dosage of cardiac medications used to treat women with heart disease. Women may have a different vasomotor tone compared to men and, thus, may require less nitrates. Only further research will give us the answers to guide clinical practice decisions.

  • Thrombolytic Therapy: The main complication associated with thrombolytic therapy in women is bleeding, especially intracranial bleeding. The reason for this increased incidence in women may be dose related.

  • PCI: The most common reported complications associated with angioplasty include bradycardia, hypotension, and coronary artery dissection. However, dissection is becoming less common as advances and improvements are made in angioplasty catheters.

  • CABG Surgery: During the operative phase, incomplete revascularization (resulting in angina, dyspnea, and sub-sequent restricted activity) may occur due to women's smaller coronary arteries and difficulty in anastomosis. However, improved surgical tools and techniques have minimized the difficulties. Reports have also shown that women have longer hospital stays, greater complication rates, and higher postoperative morbidity, as previously suggested.

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