Mr. W.G. is a 53-year-old white man who began to experience chest discomfort while playing tennis with a friend. At first, he attributed his discomfort to the heat and having had a large breakfast. Gradually, however, discomfort intensified to a crushing sensation in the sternal area and the pain seemed to spread upward into his neck and lower jaw. The nature of the pain did not seem to change with deep breathing. When Mr. G. complained of feeling nauseated and began rubbing his chest, his tennis partner was concerned that his friend was having a heart attack and called 911 on his cell phone. The patient was transported to the ED of the nearest hospital and arrived within 30 minutes of the onset of chest pain. In route to the hospital, the patient was placed on nasal cannula and an IV D5W was started. Mr. G. received aspirin (325 mg po) and 2 mg/IV morphine. He is allergic to meperidine (rash). His pain has eased slightly in the last 15 minutes but is still significant; was 9/10 in severity; now7/10. In the ED, chest pain was not relieved by 3 SL NTG tablets. He denies chills.
Case Study Questions
For patients at risk of developing coronary artery disease and patients diagnosed with acute myocardial infarct, describe the modifiable and non-modifiable risk factors.
What would you expect to see on Mr. W.G. EKG and which findings described on the case are compatible with the acute coronary event?
Having only the opportunity to choose one laboratory test to confirm the acute myocardial infarct, which would be the most specific laboratory test you would choose and why?
How do you explain that Mr. W.G temperature has increased after his Myocardial Infarct, when that can be observed and for how long? Base your answer on the pathophysiology of the event.
Explain to Mr. W.G. why he was experiencing pain during his Myocardial Infarct. Elaborate and support your answer.
Full Answer Section
Non-modifiable:
- Age (risk increases over 50 for men)
- Family history of CAD
- Gender (men are at higher risk)
- Ethnicity (certain ethnicities have higher risk)
2. Expected EKG Findings and Aligned Case Features:
Mr. W.G.'s persistent chest pain radiating to the neck and jaw, not relieved by nitrates, aligns with potential ischemic changes on his EKG. We might expect to see:
- ST-segment elevation in specific leads, indicating blocked or partially blocked coronary arteries.
- QRS widening, possibly suggesting damage to the heart muscle.
- T-wave changes, potentially reflecting myocardial injury.
3. Most Specific Laboratory Test for AMI:
While multiple tests can support an AMI diagnosis, considering Mr. W.G.'s acute presentation, the most specific initial test would be:
- Troponin: Cardiac-specific proteins released from damaged heart muscle. Elevated troponin levels are highly indicative of AMI.
Other helpful tests include:
- Creatine kinase-MB (CK-MB): Muscle enzyme with a fraction specific to the heart. Elevated CK-MB can support AMI diagnosis.
- Electrolytes and inflammatory markers: To assess overall health and potential complications.
4. Temperature Increase after AMI:
A slight temperature increase within 24-72 hours after an AMI is not uncommon. This is due to:
- Tissue inflammation: Damaged heart muscle triggers an inflammatory response, raising body temperature.
- Stress response: The body's stress response releases hormones that can elevate temperature.
- Superimposed infection: In some cases, infection can complicate an AMI, further contributing to fever.
It's important to monitor Mr. W.G.'s temperature and other vital signs to assess potential complications.
5. Explanation of Mr. W.G.'s Pain during AMI:
The crushing chest pain Mr. W.G. experienced is due to ischemia, meaning decreased blood flow and oxygen supply to the heart muscle. This causes:
- Build-up of metabolic waste products: The starved heart muscle produces lactic acid, causing pain and discomfort.
- Activation of pain receptors: Nerve fibers in the heart and surrounding tissues are stimulated by the ischemic environment, resulting in pain.
- Referred pain: Pain originating from the heart can be felt in the chest, neck, jaw, back, and arms due to shared nerve pathways.
The crushing nature of Mr. W.G.'s pain, radiating to other areas, further supports the possibility of an AMI.
Important Note: This information is for educational purposes only and should not be interpreted as medical advice. Always consult a qualified healthcare professional for diagnosis and treatment.
Mr. W.G.'s case highlights the importance of recognizing warning signs of AMI and seeking immediate medical attention. Early diagnosis and intervention can significantly improve outcomes and minimize damage to the heart muscle.
Sample Answer
Mr. W.G.'s Case: Examining Heart Attack Signs and Risks
Mr. W.G.'s symptoms and history strongly suggest an acute myocardial infarction (AMI), commonly known as a heart attack. Let's delve into the details to understand the underlying factors and potential tests.
1. Risk Factors for Coronary Artery Disease (CAD) and AMI:
Modifiable:
- Smoking
- Unhealthy diet (high in saturated fat, cholesterol, sodium)
- Physical inactivity
- Obesity
- High blood pressure
- Diabetes
- High cholesterol
- Excessive alcohol consumption
- Stress