Nursing Practice 3: Pathophysiology and Pharmacology Clinical Scenario

This report analyzes a clinical scenario involving a patient with a history of coronary heart disease and diabetes, presenting with potential symptoms of angina and acute coronary syndrome. The report begins by justifying the need for an ECG, followed by an exploration of the causes and pathophysiology of angina, including the role of coronary artery disease and the body's compensatory mechanisms. Different types of angina, including stable and unstable angina, STEMI, and non-STEMI are discussed. The analysis continues with an interpretation of the patient's ECG, including heart rate estimation and P wave analysis, and identifies potential signs of a heart attack. The report then outlines the clinical criteria for diagnosing acute coronary syndrome, including ECG abnormalities, blood tests, and common signs and symptoms. It also examines the mechanisms of action, complications, and nursing considerations for various medications used in treating heart conditions, such as GTN, Diltiazem, Pravastatin, Aspirin, Ticagrelor, and Morphine. The report further discusses the benefits of combining Aspirin and Ticagrelor and the controversies surrounding Morphine use. Finally, the report touches on the impact of depression on patients with chronic illnesses.

Nursing
Student’s name:
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Introduction
People suffeing from heart conditions often experience sudden changes in signs and symptoms.
Close monitory is therefore needed as a slight change can signify onset of serious complications.
Question 1
An electrocardiogram is able to show electrical activity of the heart at rest. It can also show any
signs of the arterial blockage, cardiac enlargement due to hypertension, detect heart disease and
heart attack occurrence (Hassan 2015). Since Betsy has a history of coronary heart disease and
coronary artery bypass graft, it is important to perform an ECG whenever the patient feels any
discomfort. In addition, there is some silent sign of heart attack including; chest discomfort,
nausea, indigestion, dizziness, sweating arm pain and others. Performing an ECG to Betsy is
therefore important in case the symptoms she is feeling are silent signs of a heart attack.
Question 2
Causes
According to Puelacher et al (2018), angina is a type of chest pain that is caused due to reduced
blood flow to the heart muscles. The main cause of angina is coronary heart disease which
causes narrowing of coronary artery reducing blood flow to the heart muscles. Other
precipitating factors are exposure to cold, some medicine, alcohol, stress, and cocaine use.
Patophysiology
The most common type of angina is angina pectoris which occurs when oxygen supply to the
muscles is lower than the demand. Oxygen is usually delivered to the heart by arteries and
arterioles which include the pericardial and myocardial arteries. They end up supplying various
muscles of the heart as they branch into a number of capillaries. Normally, there is very minimal
resistance in these vessels and therefore blood supply is to the maximum. However, in diseases
such as coronary heart disease, there is narrowing of arteries due to deposition of atherosclerotic
plaques which subsequently increase blood pressure resulting in decreased blood supply to the
muscles. When this occurs, the body can compensate through autoregulation to some extend.
This is achieved through dilation of myocardial vessels when the body detects decreased oxygen

supply. This leads to a sudden increase in the flow of blood to the muscles and therefore eases
the pain due to ischemia. The main mediators in this process are adenosine which is a potent
vasodilator and nucleotides such as nitric oxide.
The endothelial layer also plays an important role when intact (Goto 2018). It usually promotes
vasodilation and prevents sclerotic plaque and thrombus formation. It also synthesizes tissue
plasminogen activator and nitric oxide. When the layer is destroyed or damaged either
mechanically or by chemical assault, then there is a reduced synthesis of nitric oxide and other
vasodilators. Damage can also be as a result of ischemia which further worsens the disease. The
prognosis of angina is largely dependent on the number of vessels and extends of vessels
obstruction. When a lower number of obstructions such as one or two vessels obstruction, then
the level of survival is promising about 80% survival rate. However, if the obstruction of vessels
is about 80% and above, then the chances of survival are very low. This is because there is an
increased risk of vasospasm and thrombosis which can cause a heart attack. Prognosis is also
dependent on the type of angina the patient is suffering from.
Types of angina stable, unstable, STEMI and non-STEMI
There are different types of angina. One of them is stable angina which is more common. The
attacks are triggered by for example stress or alcohol use and exercise but the pain stops when
the person rests. Another type is unstable angina which is more serious than stable angina.
Attacks are more unpredictable and the pain can persist even when the person is at rest. STEMI
(ST-elevation myocardial infarction) and nonSTEMI (non-ST- elevation myocardial infarction)
are types of acute coronary syndrome (Iqbal et al 2018). STEMI occurs when there is a sudden
complete blockage of the coronary artery and there resulting in a sudden heart attack due to
sudden oxygen deprivation to the heart muscles. In non-STEMI, coronary artery blockage is
gradual but the artery is severely narrowed but not blocked. This results in very minimal blood
supply to the muscles. The acute coronary syndrome can be aggravated by certain factors such as
aging, obesity, high blood pressure, diabetes, cigarette smoking and lack of physical exercise.
Betsy has a history of hypertension and also diabetes mellitus which are the main risk factors of
acute coronary syndrome.
Question 3

The rhythm of the heart is regular this is because all the signals recorded from the aVR lead are
deflected downwards. There is also the occurrence of a P wave before each QRS complex and it
has sinus morphology. The heart rate estimation from an electrocardiograph is obtained by
counting all the squares between the QRS complex. 5 large squares on the horizontal axis
represented 250mm is equal to one second. Therefore, if the total number of large squares
counted between the QRS complex is 5, then the heart rate will be 60 beats per minute. If the
total number of squares counted between the QRS complex is 3, then the heart rate will be 100
beats per minute. Finally, 2 squares indicate that the heart rate is 150 per minute. From Betsy’s
ECG the total numbers of squares between the QRT complexes are 3-4 squares. Therefore, the
estimated heart rate is 80-90 beats per minute (Jeroudi et al 2015).
A P wave in an electrocardiogram represents arterial depolarization which results in the
contraction of arteries. Normally, the right atrial starts to contract followed by the left artery as
waves from the sinoatrial node reaches the left atria first before reaching the ventricles. The P
wave represents the contraction of both the right and the left atria as it is superimposed. The P
wave should occur at each contraction when the atria are depolarized. From Betsy’s ECG, the P
wave occurs in each depolarization. According to Belfort et al (2015), ST segment in an
electrocardiogram represents the interval between the depolarization of the ventricles and
repolarization of ventricles.. This is should be a flat section on the ECG graph as it is isoelectric.
Any elevation may indicate a heart attack or myocardial infarction. From Betsy’s
electrocardiograph, the ST level is slightly elevated and this may show that Betsy is at risk of a
heart attack or a cardiac failure. My interpretation of Betsy’s ECG is that she has a normal
heartbeat as the normal range is between 60 and 100 beats per minute. The rhythm is regular and
normal but Betsy may be having a sign of heart attack occurrence or she might be at risk of
experiencing a heart attack.
Question 4
An acute coronary syndrome is a condition that results when there is a sudden blockage or
sudden decrease in blood flow to the heart muscles and therefore a sudden decrease in oxygen
supply (Cannon et al 2015). In order to diagnose the acute coronary syndrome, the three central
findings required are an electrocardiogram, blood tests and signs and symptoms of the acute
coronary syndrome. Common electrocardiogram abnormalities that can be observed in acute

coronary syndrome include T-wave tenting or T-wave inversion. ST- wave may be elevated or
depressed depending on whether it is an ST-segment elevation myocardial infarction or a non-
ST- elevation myocardial infarction. There can also be a pathologic Q wave. Blood can also be
tested for some specific enzymes. Some enzymes can be tested in blood if heart tissues have
been damaged and if these enzymes are present then it is an indication of a heart attack. Most
common are the Troponin T or I and sometimes isoenzyme of creatinine kinase is used.
Myoglobin from muscles and creatinine kinase can also be tested as they are early signs of acute
coronary syndrome. Some common signs and symptoms of the acute coronary syndrome are a
pain in the chest that can radiate to the arm and also the jaw. The pain can occur at rest or it can
occur with exhaustion. The patient may also experience shortness of breath, especially when
exercising and sweating and chest pressure may be experienced. Other advanced diagnostic tests
for acute coronary syndrome include; coronary angiogram, echocardiogram, myocardial
perfusion imaging and stress test (Fanaroff et al 2015).
Question 5
Generic name GTN Diltiazen Pravastatin
Drug group Nitrate family. Nondihydropyridine
calcium channel
blockers.
Statins.
Mechanism of action It is a potent
vasodilator which
causes relaxation or
muscles of both
arteries and veins.
Therefore, it causes
dilatation of both
arterial and venous
beds encouraging
peripheral pooling
and decreased blood
It is a vasodilator
acting as a calcium
channel antagonist.
The prevent calcium
from entering the
heart muscles
resulting in decreased
blood pressure. They
also relax and dilate
blood vessels by their
action on the muscles
It inhibits the function
of
hydroxymethylglutaryl-
CoA reductase which
leads to the synthesis of
cholesterol. It also
inhibits the synthesis of
very-low-density
lipoprotein. This is a
precursor or low-
density lipoprotein. In

flow to the heart.
This decreases
ventricular pressure
and thus reduces
heart overworking.
This results in
decreased myocardial
oxygen consumption.
on the walls of
arteries further
lowering blood
pressure.
overall it lowers
cholesterol levels and
low-density lipoprotein
levels. It also leads to
an increase in high-
density lipoprotein
which is good.
Complications/side
effects
Tachycardia,
bradycardia, and
hypotension.
Dizziness,
hypotension,
weakness, and
shortness of breath.
Muscle pain, difficulty
breathing, extreme
tiredness.
Nursing
considerations
Vital signs should be
taken regularly with
the administration of
the drug and fluid
input and output
chart should be
monitored closely.
Check vital signs
before administering
and after
administration. Pay
attention to any signs
and symptoms of
hypotension.
The occurrence of
myopathy, myalgia and
muscle weakness
should be considered. It
should be used
cautiously in patients
with renal failure.
Question 6
Aspirin is one of the non-steroidal anti-inflammatory drug. It prevents the synthesis of
prostaglandins by inhibiting the platelet-dependent cyclooxygenase (COX) (Mishra et al 2017).
Aspirin irreversibly inactivates the COX-1 enzyme which produces thromboxane A2 a which
ptomotes platelet aggregation. This, therefore, prevents the activation of the blood clotting
cascade which results in vascular blockage especially vessels of the heart. In cardiovascular
diseases, aspirin contribute to endothelial dysfunction by blocking the dependent

vasoconstrictors, especially in arteriosclerosis. This eventually leads to vasodilation, reduced
thrombosis and prevent worsening of arteriosclerosis. Inhibition of ADP P2Y (12) receptor
causes a reduction in atherothrombotic events in a high-risk setting in patients with acute
coronary syndrome and percutaneous coronary interventions. Ticagrelor is a P2Y (12) reversible
receptor antagonist (Xia, Liang, Zhang and Liu 2019). It has a rapid and consistent antiplatelet
effect and has been found to be more effective in prevention of ischemic events esspecially in
acute coronary syndrome. It has a favorable safety profile with minimal risk of major bleeding.
Combination of aspirin and ticagrelor drugs produces a synergistic effect as they act on different
receptors. They also have the same function of preventing clot formation and therefore this will
improve cardiac function in people with acute coronary syndrome.
Question 7
According to McCarthy et al (2016), morphine is an analgesic drug mostly used in the treatment
of severe pain such as cancer pain, neuropathic pain and has been found helpful in patients with
acute coronary syndrome. Morphine works by activation of the hypothalamic-pituitary-adrenal
axis increasing corticosteroid production and activating the sympathetic nervous system. There
has been a controversy on morphine use in pain management of patients with acute coronary
syndrome. Basing on recent studies morphine has been associated with increased risk of
recurrent myocardial infarction. There is higher confidence that morphine decreased the
antiplatelet effect of drugs that inhibit the P2Y12 receptor. Even with this, more research is still
needed.
Question 8
Depression is a mental health disorder that is characterized by a lack of interest in daily activities
and persistent depressed mood. These characteristics are intense such that they have an impact
on activities of daily living. It has been found that approximately one-third of people suffering
from chronic illnesses have a tendency to develop depression. This is mainly because of the
change in lifestyle and unbearable symptoms. In the case of Betsy, she is not able to perform her
duties the way she used to due to her current medical condition. Pain and weakness are some of
the reasons that may limit her from performing her chores. Patients also tend to develop
clinically significant depression but it is a treatable condition if managed well. About 18-20% of

people with coronary artery disease have been found to develop depression (Nanthakumar,
Bucks and Skinner 2016). Depression can be serious and can even lead to suicide. Therefore,
early diagnosis and treatment of depression related to chronic illnesses are very important as it
also contributes to the overall improvement of a medical condition, improved quality of life and
ease in following the treatment regime.
Conclusion
Acute coronary disease can present with silent symptoms that should b noticed early and
interviened promptly to avoid serious complications. Therefor, in patients with any heart
condition, any change in their breathing pattern or any vital signs should be looked at closely.

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