Case Study: Betsy's Care in Acute Coronary Syndrome

This case study discusses the care of Betsy, a 72-year-old with multiple complications and cardiovascular conditions. It covers pathophysiology, risk factors, diagnostic data interpretation, medications, and depression associated with coronary heart disease.

Bachelor of Nursing

Introduction:
In this assignment, case of Betsy is being discussed. She is 72 years old with multiple
complications like cardiovascular, respiratory and metabolic complications. Moreover, she is
consuming multiple medications; since, she is associated with multiple disease conditions. In
this essay, different aspects related to her care will be discussed like pathophysiology of the
disease condition, risk factors associated with the disease condition, interpretation of
diagnostic data like ECG and clinical criteria for the disease condition. Moreover,
medications will be discussed in terms of class of drug, mechanism of action, side effects and
nursing consideration during administration of medications. Benefits and risk factors of
administration of ticagrelor, aspirin and morphine will also be discussed. Depression
associated with coronary heart disease will also be discussed.
Body:
Question 1 :
Coronary artery disease (CHD) is the narrowing of the coronary arteries which supply
oxygen and blood to the heart. CHD mainly occur due to accumulation of cholesterol on the
artery walls which create plaques. Hence, there would be inadequate arterial blood flow.
Normal ECG pattern changes during inadequate coronary artery blood flow. ECG is useful in
determining rate and rhythm of the heartbeats. Changes in the heart is associated with new
coronary artery events which can be effectively monitored through ECG. Hypertension is an
asymptomatic disease. However, ECG is useful in identifying cardiac electrical remodelling
which provide significant information related to disease stratification. ECG in hypertensive
patients also be useful in identifying damage to heart or blood vessels. Since, Betsy is
associated with cardiovascular conditions; it would be helpful to carry out her ECG. ECG in
Betsy would be helpful in identifying cholesterol clogging during blood supply to heart, heart
attack in the past, heart enlargement at one side and abnormal heart rhythms (Darpo, 2015;
Burke, Wang, Blease, Levy, and Magnani, 2014).
Question 2 :
2a) Angina mainly occur due to imbalance in the heart’s oxygen demand and supply.
Atherosclerotic plaques are mainly responsible for the impeded blood flow. Obstruction in
the blood flow can be fixed or dynamic as in atherosclerosis or coronary spasm respectively.

In unstable angina, vulnerable plaque formed. Tissue factor is present within the necrotic core
of the plaque. After exposure to blood, clotting cascade gets activated and thrombosis occur.
After the disruption of fibrous cap, tissue factor gets exposed.
Coronary occlusion due to plaque rupture or erosion is mainly responsible for the occurrence
Angina. Rupture or erosion resulting in coronary occlusion is the predominant mechanism in
Non-STEMI and STEMI. Unstable angina and NSTEMI occur mainly due to same
pathophysiological mechanism which result in unstable atherosclerotic plaque which lead to
non-occlusive thrombus or complete thrombosis formation. In NSTEMI, partial or temporary
blockade occurs which results in relatively small damage (Ando, Takagi, and Grines, 2017).
STEMI mainly occur due to unexpected and prolonged blockage of the blood vessels which
affects large area of heart muscles. In STEMI, plaque rupture is the prominent mechanism
followed by plaque erosion. In case of NSTEMI, plaque erosion is the prominent mechanism
followed by plaque rupture. Plaque rupture is associated with lipid rich plaque, collagen poor
plaque, macrophage rich inflammation and fibrous cap. Plaque erosion is associated with
plaque with extracellular matrix, proteoglycan, glycoaminoglycan; however, without
inflammatory cells, no fibrous cap and no large lipid core (Tousoulis et al., 2013).
2) Hypertension and type 2 diabetes mellitus are the risk factors associated with acute
coronary syndrome in Betsy.
Question 3 :
Betsy’s ECG is exhibiting regularly irregular rhythm. This regularly irregular heart rhythm
indicates heart block. Spaces between the R and R are useful in interpreting rhythm in the
ECG. Equal spaces between R and R indicate normal heart rhythm; however unequal spaces
between the R and R indicate irregular rhythm. Heart rate from the Betsy’s ECG need to be
calculated by measuring number of R waves in 6 seconds and multiplied by 10. This formula
should be used to calculate heart rate in this case because Betsy is exhibiting irregular
rhythm. Since, Betsy is exhibiting irregular rhythm; heart rate is more than 100 beats per
minute which is higher than the normal heart rate. ST segment depression was observed in
case of Betsy’s ECG. Depression of ST segment indicate NSTEMI, myocardial ischemia and
posterior myocardial ischemia. Presence of irregular P wave indicate atrial flutter with
variable block (Klabunde, 2017; Burke, Wang, Blease, Levy, and Magnani, 2014).
Question 4 :

ECG indicate T-wave tenting or inversion, elevation in the ST segment and pathologic Q
waves in the acute coronary artery syndrome patients. Based on the intensity of ST segment
elevation, lesions in the different arteries like right coronary artery, left circumflex coronary
artery, proximal LAD coronary artery and distal LAD coronary artery can be diagnosed.
Troponin T (TnT) elevation > 1.0 ng/ml and creatine kinase–MB isoenzyme (CK-MB)
elevation are considered as the diagnostic features of the acute coronary syndrome. Elevated
levels of troponin would be helpful in the identification of patients with increased risk of
death due to acute coronary syndrome (Eisen, Giugliano, and Braunwald, 2016). CK-MB is
useful in the early diagnosis of myocardial infraction. CK-MB level would not be useful in
the detection of infract size; however, it would be helpful in detecting reinfarction. Complete
coronary occlusion involving plaque disruption, intracoronary thrombus and microemboli are
considered as the diagnostic features of acute coronary syndrome (Makki, Brennan, and
Girotra, 2015).
Question 5 :
GTN Diltiazem Pravastatin
Drug group Nitrates Calcium channel
blocker
Statin
Mechanism of
action
At the lower doses,
GTN exhibit
dilation effect more
on veins as
compared to the
arteries. Thus, it
reduces preload
which is blood
volume in the heart
after filling. GTN
produces free
radical like nitric
oxide (NO). NO
activate enzyme
guanylate cyclase;
hence, there would
be consequent rise
in guanosine 3'5'
monophosphate
(cyclic GMP) in
smooth muscle and
other tissues.
Subsequently, it
results in the
Diltiazem exhibit
its action by acting
as a calcium
channel blocker;
hence, it is useful
in treatment of
blood pressure,
angina and cardiac
arrhythmias. It
produces its action
by acting as potent
vasodilator,
augmenting blood
flow and reducing
heart rate through
strong depression
of A-V node
conduction.
Diltiazem exhibit
its action through
inhibiting
extracellular
calcium influx
through both the
Pravastatin exhibit its
action through
lowering lipoprotein. It
exhibits its action
through inhibiting
hydroxymethylglutaryl-
CoA (HMG-CoA)
reductase. It act as
reversible competitive
inhibitor of HMG-
CoA reductase by
inhabiting active site of
enzyme. This enzyme
plays role in the
conversion of HMG-
CoA to mevalonate
which is a rate limiting
step in cholesterol
biosynthetic pathway.
Pravastatin also exhibit
its action through very-
low-density
lipoproteins which are
precursors for synthesis

myosin light chain
dephosphorylation.
Dephosphorylation
of myosin light
chain regulate
contractions of
smooth muscle
which lead to
vasodilation
(Divakaran and
Loscalzo, 2017).
myocardial and
vascular smooth
muscle cell
membranes. It
results in the
contractile process
inhibition of the
myocardial smooth
muscle cells which
results coronary
and systemic
arteries dilation
which improves
oxygen delivery to
myocardial tissue.
Diltiazem is a
potent vasodilator
for coronary
vessels and mild
vasodilator for
peripheral vessels.
Hence, it is useful
in reduction of
peripheral
resistance and
afterload (Velayati
et al., 2016).
of low-density
lipoproteins (LDL).
These reduction
reactions are helpful in
augmenting cellular
LDL receptors which
lead to increased LDL
uptake resulting in
elimination of LDL
from the blood. Hence,
it produces effect
through reducing LDL,
cholesterol,
triglycerides and
increasing HDL levels
(Al-Badr and Mostafa,
2014).
Complications/Side
effects
Serious side effects
of GTN include
shortness of breath
and swelling of the
face, lips, tongue,
mouth and throat.
Shortness of breath
might exaggerate
condition of Betsy
because she is
already
experiencing it due
to her past medical
history like Chronic
Obstructive
Pulmonary Disease
(COPD). Swelling
of the face, lips,
tongue, mouth and
throat result in
difficulty in
swallowing or
Diltiazem
consumption is
associated with
mild and transient
increase in the
serum
aminotransferase
which indicate
hepatotoxicity.
This side effect of
diltiazem is
relevant to Betsy
because she is
consuming
multiple drugs. In
elderly patients
consuming
multiple drugs
might lead to liver
damage.
Dizziness is
another prominent
Chest pain is one of the
prominent side effect
of pravastatin. Since,
Betsy is associated
with coronary artery
disease; there might be
possibility of
exaggerated chest pain
in him due to
consumption of
pravastatin; though, she
was not having chest
pain.
Trouble in breathing is
another side effect of
pravastatin
consumption.
Pravastatin
consumption might
amplify her shortness
of breathing condition

breathing which
might exaggerate
shortness of breath
in her (Divakaran
and Loscalzo,
2017).
side effect of
diltiazem which is
relevant to Betsy.
Betsy is associated
with high blood
pressure and
shortness of breath.
Both the conditions
would exaggerate
dizziness in Betsy
which occur due to
diltiazem. Both
high blood pressure
and shortness of
breath would lead
to light headedness,
loss of balance,
fainting and effect
on eyes and ears
(Velayati et al.,
2016).
(Al-Badr and Mostafa,
2014).
Nursing
considerations
GTN need to be
administered with
caution in elderly
patients because
patients consuming
multiple
medications exhibit
hypotension
associated with
angina (Divakaran
and Loscalzo,
2017).
Nurse need to
monitor carefully
on regular basis
because Betsy is
consuming GTN.
Since, both the
drugs exhibit
antihypertensive
effect; there might
be possibility of
hypotension.
Nurse need to
report heart rate,
shortness of breath
and noticeable
dizziness in Betsy
because diltiazem
affects all these
factors. Hence, to
eliminate chances
of further deviation
from the normal
values; it is
necessary for the
nurse to report
these values to
physician on
regular basis
(Velayati et al.,
Nurse need to perform
liver function test.
Evaluate cholesterol
and triglycerides levels
prior to and after
treatment (Al-Badr and
Mostafa, 2014).

2016).
Question 6 :
Ticagrlor exhibit its action through interacting with platelet P2Y12 ADP-receptor and prevent
signal transduction and platelet activation.
Thromboxanes are accountable for platelet aggregation which lead to formation of blood clot.
Aspirin exhibit its action through irreversibly inhibiting thromboxane A2 formation in
platelets which inhibit platelet aggregation.
Combination of Ticagrelor and aspirin would be helpful in the treatment of coronary artery
disease in Betsy. Ticagrelor exhibit its effect through blockade of P2Y12 platelet receptor
which do not exhibit antiaggregatory effect of aspirin which can be seen after administration
of clopidogrel. Moreover, aspirin exhibit its antiplatelet effect through different mechanism.
Hence, effective treatment for Betsy can be provided without any side effects (Dobesh,
Varnado, and Doyle, 2016).
Question 7:
Morphine is useful for the pain management in patients with acute coronary syndrome. It is
recommended in patients with acute coronary syndrome because pain modulation produces
sympathetic nervous system activation which decreases myocardial oxygen requirement.
However, use of morphine in acute coronary patients is questionable due to certain
complications associated with morphine consumption. Patients with acute coronary syndrome
receiving morphine are associated with augmented risk of recurrent myocardial infarction.
Acute coronary syndrome patients receiving morphine, are associated with reduced
absorption of antiplatelet medications and delayed maximal effect of antiplatelet medications.
These effects observed in morphine administered patients due to inhibition of gastrointestinal
motility and gastric emptying with emesis. Morphine also exhibit hypotension and
bradycardia which results in reduced coronary perfusion (McCarthy, Mullins, Sidhu,
Schulman, and McEvoy, 2016).
Question 8:
Depression is one of the major robust risk factor and prognostic marker for chronic coronary
heart disease. In coronary artery disease, it has been established that approximately 20 %

patients rich criteria for depressive disorder and approximately 47 % patients exhibit
depressive symptoms. Moreover, patients with depression have more chances of angina
development, physical limitations and diminished health-related quality of life. Many
biological mechanisms demonstrate association between depression and coronary heart
disease. These biological mechanisms include platelet reactivity, autonomic nervous system
imbalance, inflammation, sleep disturbance and circadian rhythm disruption. Elevated levels
of platelet factor 4 and β-thromboglobulin were evident in coronary heart disease patients
with depression as compared to the patients without depression. Melatonin is a hormone
derived from pineal body which is a prominent marker for circadian rhythm in humans. It has
been demonstrated that melatonin circadian profile alters in patients with depression
(Granville Smith, Parker, Rourke, Cvejic, and Vollmer-Conna, 2015).
Conclusion:
Patients like Betsy, with complex disease condition need to be provided with high level
assessments and knowledge for providing effective nursing care. Nurse professionals
provided effective nursing services to Betsy through gaining knowledge about
pathophysiology of the disease condition, medication information and other probable nursing
strategies. Nurses professionals performed effective assessment to collect all the necessary
information of Betsy by carrying out ECG; though, it was not warranted in her case.

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