Acute Coronary Syndrome Case Study: Patient with Multiple Conditions

This case study examines a 60-year-old patient named Thomas, who presents with acute coronary syndrome and several comorbidities, including hypertension, hyperlipidemia, type 2 diabetes mellitus, and a history of rheumatic heart disease. The analysis delves into the pathophysiology of Thomas's symptoms, focusing on the impact of long-term medication use, particularly metformin, and its associated side effects like vitamin B12 deficiency and shortness of breath. The case study also explores the potential for myocardial infarction and atherosclerosis, given the patient's symptoms and medical history, including previous bypass surgeries. Alternative medications and lifestyle adjustments are considered to manage Thomas's condition and alleviate his symptoms. Desklib provides access to similar solved assignments and study resources to aid students in their learning.

Acute Coronary Syndrome

Table of Contents
INTRODUCTION...........................................................................................................................1
MAIN BODY...................................................................................................................................1
CONCLUSION................................................................................................................................1
REFERENCES................................................................................................................................2

INTRODUCTION
Acute coronary syndrome refers to sudden reduction of blood flow to heart due to
blockage in arteries. It is usually caused by clot formation or plaque rupture in the arteries of
heart. Patient may experience chest pressure while resting, dizziness, weakness, shortness of
breathe and sudden heart stoppage. In this assessment, there is a case study of a patient who is
suffering from a number of health complication such as hypertension, hyperlipidaemia and type
2 diabetes mellitus. In this project, pathophysiology related to the symptoms of Thomas has been
discussed. Finally this project will going to discuss about the diabetes type two diabetes like
diabetes mellitus and rheumatoid arthritis.
MAIN BODY
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Patient name: - Thomas
Patient sex: - male
Patient age: - 60 years’ old
Complications: - Type 2 diabetes mellitus, rheumatic
fever, hypertension and hyperlipidaemia.
Type 2 diabetes mellitus
 Type 2 diabetes mellitus is known as
insulin independent diabetes in which
body resists the effects of insulin or does
not secrete enough insulin for the process
of metabolisms of sugar.
 Diabetes is a chronic condition which
cannot be cure but patient can manage it
with changing his lifestyle.
Metformin is drug of choice in case of type 2
diabetes mellitus. Patient is diagnosed with diabetes
before six years and he was taking metformin as
antidiabetic drug.
Fasting blood sugar test
 Normal blood sugar level= 100 mg/dL
 Elevated blood sugar level= 126 Mg/dL
As Thomas has been prescribed metformin he may
experience various symptoms such as weakness,
sickness, tiredness, nausea, vomiting, stomach pain,
rapid shortness of breath and dizziness. Thomas is
already complaining increasing shortness of breath.
Last night, he woke up at 2.00am and he sat on his
recliner. He went to toilet and was feeling tiered by
coming back on his recliner. Metformin may also
cause contradiction such as impaired hepatic
function, acute metabolic acidosis, renal dysfunction
and hypersensitivity to metformin.
For last 6 years, Thomas has been administering
metformin and it caused vitamin B 12 deficiency.
Shortage of vitamin B 12 always make him feel tired,
faint and breathless. In this situation, he must take
vitamin B12 supplements which would assist him to
reduce all the side effects.
Hyperlipidaemia
 It is a chronic condition where
level of cholesterol get increased
in the blood.
 Low density lipoprotein as
called bad cholesterol whereas
high density lipoproteins are
called good cholesterol. HDL
carries cholesterol back to the
liver.
 LDL- Less than 160 mg/dL
 HDL – Greater than 60 mg/dL
 Triglycerides- greater than 200
mg/dL
Since many years, he has
suffered from hyperlipidemia
and thus administering
simvastatin. Simvastatin may
cause a number of side effects
such as memory loss, itching,
nausea, stomach pain,
constipation and confusion.
Hypertension
 Hypertension is also
known as elevated blood
pressure where the
pressure of blood gets
increased against the
wall of artery.
 Hypertension is caused
due to long term kidney
infections, unhealthy
lifestyle choices, lack of
physical activity and
genetic characteristics.
As Mr. Thomas was diagnosed
with hypertension he has been
administering enalapril which is
an angiotensin converting
enzyme inhibitor. Enalapril
assist body to relax the blood
Enalapril may cause shortness
of breath, swelling in hand,
face or mouth, itching,
hoarseness, rash and difficulty
in swallowing. Contradiction
associated with enalapril may
include collagen vascular
disease, myocardial infraction,
Other alternative medication for
Thomas: -
 Lisinopril
 Ramipril
 Candesartan
 Irbesartan
 Valsartan
 Olmesartan

other medications: -
lovastatin, pravastatin,
rosuvastatin, fluvastatin,
atovstain
Thomas blood pressure: -
189/103
SpO2 calculated: - 73%
BP measurement test shows, he
is a high blood pressure patient
and requires the administration
of antihypertensive drugs.

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In a given case study, Mr. Thomas complained for shortness of breath. Six years ago, he
diagnosed with type 2 diabetes mellitus and has been administering metformin. Administering
metformin for so long causes short of breath, weakness, dizziness, diarrhoea, loss of appetite,
sickness and metallic taste in mouth Hahn and at. al., (2018). Due to this side effect he started
feeling weak and tired and had difficulty on coming back to his recliner. Administration of
metformin is associated with deficiency of vitamin B12. Prevalence of anaemia also becomes
higher with the long use of metformin. Lower level of vitamin B12 causes neuropathy
prevalence. Thomas need to administer cobalamin supplementation to overcome with this
deficiency. Deficiency of vitamin B12 made him feel faint, breathlessness tired and lack of
energy. Due to lack of energy, he was not able to perform his daily activities. Vitamin deficiency
may result to megaloblastic anaemia which is caused by the scarcity of vitamin B12 Tahhan and
et. al., (2020). He also suffered from hypertension and blood pressure management was
189/103. In hypertension, kidney is both the target a contributing organ. Arterial blood pressure
gets increased with the dysfunctionality of kidney. Important factors, play crucial role in
pathogenesis of hypertension including rennin angiotensin aldosterone system, increased dietary
salt intake, obesity and activation of neurohormonal system. Hypertension is a condition where
the arterial pressure get increased. Increased salt intake enhances the ion concentration in the
blood. Salt narrows the blood vessels and pressure of blood against the wall of artery get
increased. Rennin angiotensin aldosterone system plays a critical role in regulation of blood
pressure. Rennin angiotensin system refers to a group of related hormones which acts to regulate
the blood pressure. Inappropriate functioning of RAAS system may cause high blood pressure.
The oxygen level monitored was less than 95% and this can cause hypoxaemia Iliescu and at. al.,
(2018). In this case vasodilators are given as decreased tissue oxygen level due to reduced
oxygen supply demands vasodilation Hahn and at. al., (2018). External oxygen supply may be
also preferred. Hypoxaemia may result from sleep apnoea, high altitude exposure and
cardiopulmonary complications. As the sign and symptoms of Thomas reflects that he may be
possible he may suffer with cardiac issues such as myocardial infarction and atherosclerosis.
Thomas also complained about peripheral oedema as his ankles and feet were swelled. He was
totally unable to walk and lie flat on bed. Thomas also experienced symptoms like chest pain and
chest tightness which are indicators of myocardial infarction. Rupture of vulnerable plaque may
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cause myocardial infarction. Myocardial infarction occurs if the muscles of heart are not getting
enough oxygen. It is very dangerous condition caused by the lack of oxygen to the heart muscles.
This occurs due to blockage in arteries. Fat get accumulated at the wall of the artery and arteries
get narrowed result lack of oxygen and blood supply to the muscles. Thomas also diagnosed with
hyperlipidaemia that means blood has too many lipids. Theses accumulated lipids are blocking
his blood vessels and his blood pressure is geeing increased. Due to blockage he experienced
shortness of breath Cavallari and at. al., (2018). Shortness of breathing and feeling tiredness are
common symptoms of atherosclerosis. Atherosclerosis is a type of lipid accumulation in the
vascular wall results to thickening and narrowing blood vessels, calcification, luminal stenosis.
Hyperlipidaemia may arise lethal complications such as cardiovascular disease, renal
dysfunction, cerebral strokes and hepatic dysfunction. It may be caused due to genetic
abnormalities and it is quite possible that Thomas had also such family history. Thomas could
improve his lifestyle in order to deal with it. Theses sign and symptoms indicates that Thomas
is a heart patient and needs a heart surgery Nabovati and et. al., (2021). Thomas also diagnosed
with type 2 diabetes mellitus. Type 2 diabetes mellitus is also known as insulin independent
diabetes in which body shows resistance to the effects of insulin. Insulin is responsible for the
metabolism of sugar, when body becomes resistance to insulin and thus sugar does not get
metabolised leads to increased blood sugar level. Increased blood sugar level make Thomas feel
tiered all the time. Thomas also noticed urinate a lot, usually a night which is a common
symptom of high blood sugar level. Since childhood, Thomas develop rheumatic heart diseases
which is caused by repeated attacks of rheumatic fever. This results to deformity and rigidity of
valve cusps and shortening of chordae tedineae. Rheumatic fever alters the walls of heart,
especially mitral wall get affected by rheumatic fever. Damage of heart walls may cause valve
regurgitation, valve stenosis and also damage muscles of heart. As Thomas developed rheumatic
heart disease he may suffer from heart failure. Rheumatic heart disease causes infection in heart
valves and forms clot in the heart valves. Due to clot formation the oxygen supply gets decreased
and Thomas starts feeling breathlessness. Due to rheumatic fever Thomas may also experience
joint pain and skin redness. His feet and ankles also get swelled due to rheumatic fever
Candelaria and et. al., (2020). Shortness of breath may also cause by lungs infection results
pneumonia. In pneumonia pathogen reaches to the alveoli and damage the wall of alveoli.
Damaged alveoli cause lack of oxygen and make Thomas feel breathless. According to the case
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report of Thomas, It is founded that he was also suffering from the exertion al angina and also
had four bypass surgery in the past years. As the symptoms of Thomas indicated, there may be
the possibility of Exertion of Angina. The cause of angina is the outcomes of an imbalance
between the myocardial oxygen demand and myocardial oxygen supply. Pathophysiology of
angina: angina is due to the decreased blood flow for the heart muscle. Blood carries the oxygen
molecule by the help of red blood cell through which the heart muscle needs to survive. At the
time of heart muscle is not getting too much oxygen, as it cause a situation like ischaemia in
which less supply of oxygen molecule reaches to heart muscle. The very common reason of the
decreased in the blood flow for the heart muscle is CAD that coronary artery diseases Campo
and et. al., (2020). The heart coronary arteries diseases can become too narrowed through the fat
depositions known as plaques. This is also known as atherosclerosis. If this plaque in the blood
vessel cause rapture or damages to the blood vessels or formation of blood clots, which can be
fast block and decrease the flow via a narrowed artery. This severely and suddenly lower the
flow of blood to the heart muscle and cause low oxygen level to the muscle. As the symptoms
show in case of Thomas, like shortness of breathing, it may be due to the angina. It is most
probable reason of shortness of breathing in the case of Thomas because in past year he took 4
by pass surgery Bainey and et. al., (2018).
CONCLUSION
From the above case study, it has been concluded that Mr. Thomas was diagnosed with a
number of complications such as rheumatic heart disease, hypertension and type 2 diabetes
mellitus. It has been analysed that administering a lot of medicines made him suffer with so
many side effects. For example, Thomas has been prescribed metformin as he was diabetic
patient. Use of metformin for so long made him feel tired and breathless. The patient was given
alternative medicines in order to overcome with side effects and deal with his heart
complications.
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REFERENCES
Books and Journals
Bainey and et. al., (2018). Population-level incidence and outcomes of myocardial infarction
with non-obstructive coronary arteries (MINOCA): Insights from the Alberta
contemporary acute coronary syndrome patients invasive treatment strategies (COAPT)
study. International journal of cardiology, 264, 12-17.
Campo and et. al., (2020). The assessment of scales of frailty and physical performance improves
prediction of major adverse cardiac events in older adults with acute coronary
syndrome. The Journals of Gerontology: Series A, 75(6), 1113-1119.
Candelaria and et. al., (2020). Health-related quality of life and exercise-based cardiac
rehabilitation in contemporary acute coronary syndrome patients: a systematic review and
meta-analysis. Quality of Life Research, 29(3), 579-592.
Cavallari and at. al., (2018). Metabolic syndrome and the risk of adverse cardiovascular events
after an acute coronary syndrome. European journal of preventive cardiology, 25(8), 830-
838.
De Vita, A and et. al., (2019). Coronary microvascular dysfunction in patients with acute Hahn
and at. al., (2018)coronary syndrome and no obstructive coronary artery disease. Clinical
Research in Cardiology, 108(12), 1364-1370.
Dong and et. al., (2018). Neutrophil to lymphocyte ratio predict mortality and major adverse
cardiac events in acute coronary syndrome: A systematic review and meta-Iliescu and at.
al., (2018)analysis. Clinical biochemistry, 52, 131-136.
Hahn and at. al., (2018). 6-month versus 12-month or longer dual antiplatelet therapy after
percutaneous coronary intervention in patients with acute coronary syndrome (SMART-
DATE): a randomised, open-label, non-inferiority trial. The Lancet, 391(10127), 1274-
1284.
Iliescu and at. al., (2018). Safety of diagnostic and therapeutic cardiac catheterization in cancer
patients with acute coronary syndrome and chronic thrombocytopenia. The American
Journal of Cardiology, 122(9), 1465-1470.
Langabeer and et. al., (2019). Gender-based outcome differences for emergency department
presentation ofnon-STEMI acute coronary syndrome. The American Journal of Emergency
Medicine, 37(2), 179-182.
Muskiet and et. al., (2018). Lixisenatide and renal outcomes in patients with type 2 diabetes and
acute coronary syndrome: an exploratory analysis of the ELIXA randomised, placebo-
controlled trial. The lancet Diabetes & endocrinology, 6(11), 859-869.
Nabovati and et. al., (2021). A global overview of acute coronary syndrome registries: a
systematic review. Current Problems in Cardiology, 101049.
Raposeiras-Roubín and et. al., (2018). Development and external validation of a post-discharge
bleeding risk score in patients with acute coronary syndrome: The BleeMACS
score. International journal of cardiology, 254, 10-15.
Schnorbus and at. al., (2020). Effects of clopidogrel vs. prasugrel vs. ticagrelor on endothelial
function, inflammatory parameters, and platelet function in patients with acute coronary
syndrome undergoing coronary artery stenting: a randomized, blinded, parallel
study. European Heart Journal, 41(33), 3144-3152.
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Shuvy and et. al (2018). Accuracy of the global registry of acute coronary events (GRACE) risk
score in contemporary treatment of patients with acute coronary syndrome. Canadian
Journal of Cardiology, 34(12), 1613-1617.
Tahhan and et. al., (2020). Enrollment of older patients, women, and racial/ethnic minority
groups in contemporary acute coronary syndrome clinical trials: a systematic
review. JAMA cardiology, 5(6), 714-722.
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