atherosclerosis

185cm

85.5 kg

SpO2: 95%

Temo: 98.6

CC: “Chest pain”

Darius Davis is a 62-year-old African America male who present to the clinical with new

intermittent chest pain. He states the onset was two months ago while raking leaves that

subsided after 10 mins of rest. Darius is able to precisely locate the pain to his midsterum. He

states the pain is intermitted with exertion and occurs three or four times a week. Pain is

characterized as a pressure or heavy weight. He has tried taking antacids and massaging the

chest to alleviate the pain with no relief. The pain has radiated to his neck on a few occasions

when he continues to exerted himself in an attempt to work through the pain. He also states once

he had shortness of breath with the pain that resolved with rest. Pain severity is a 5 or 6 on a

pain sale of 1-10. He denies fever, increased pain with inspiration, post meal, or while laying

flat.

Hctz 25mg daily – takes most of the time

Hypertension controlled on meds

Hypercholesterolemia treated with diet due to medication side-effects GERD

– occasional, treats with anti-acids

Family hx of heart disease:

Father: deceased at age 68; CAD/multiple MIs

Mother: deceased at age 71; CVA

Younger brother: age 58; DM

Older sister: age 71; CAD, MI- 3 stents

Smoker since 14, >50 pack year history

Socially drinks a few beers after work once or twice weekly Does

not exercise

He is a geologist and increased stress of work due to cut backs. 20 to

30 questions max!

Temp: 98.6 F

Pulse: 76, rhythm:

regular

BP: left: 130/84

Resp ira t io n : 12, effort:

unlabored

Additional labs or diagnostic tests:

12 lead ECG – “The ECG is central to the evaluation of stable angina in the office setting to

ensure that ACS is not missed (Gulati et al., 2021).”

Chest x-ray –“In patients presenting with acute chest pain, a chest radiograph is useful to

evaluate for other potential cardiac, pulmonary, and thoracic causes of symptoms (Gulati et al.,

2021).”

Coronary computed tomography angiography (CCTA)-“ For intermediate-high risk patients

with stable chest pain and no known CAD, CCTA is effective for diagnosis of CAD, for risk

stratification, and for guiding treatment decisions (Gulati et al., 2021).”

Lab test results can be helpful in determining whether a patient's signs and symptoms are cardiac

in nature and the level of cardiac risk include:

Fasting lipid

profile

Hemoglobin A1C

Comprehensive metabolic

panel Thyroid function test

Coronary artery calcium

score Complete blood cell

count.

CRP

High-sensitivity C-reactive protein (hs-CRP) has emerged as a leading biomarker of CVD risk

prediction (Rogers, & Baker, 2020). Obtaining a coronary artery calcium score for patients at risk

can aid compliance for patient who are hesitant to begin or rechallenge statin therapy (Rogers, &

Baker, 2020)

Consults:

Refer to cardiology: In patients where the optimal treatment strategy is indistinct and/or the

severity of risk factors put the patient at significant risk a referral to cardiology is appropriate to

improve patient outcome (Alonso, Cuevas, & Cafferata, 2019).

Therapeutic modalities:

Continue HCTZ 25mg

daily Will add:

Nitroglycerin 1 tab sublingual with onset of pain; may repeat in 5 mins for a max of 3 tabs over

15 mins.

Aspirin 81mg PO once daily

Felodipine XR 2.5mg PO once daily on empty stomach

Pravastatin 10mg PO once daily at HS

Eliminating or reducing risk factors for cardiovascular disease are a vital component in the

management for with stable angina. A strong interaction exists between CAD and hypertension

that accounts for 25%-30% of acute myocardial infarctions (Unger et al., 2020). The patients’

blood pressure is not at goal with the monotherapy of HCTZ, given his race as an African

American male it is appropriate to add a calcium channel blocker. Furthermore, the addition of a

calcium channel blocker will also improve anginal symptomatology by causing coronary and

peripheral vasodilation and reducing contractility (Williams et al., 2018). Calcium channel

blockers are second line treatment for angina however, given the patients possible respiratory

issue based on physical assessment calcium channel blockers are preferred in patients with

obstructive airways disease (Rogers, & Baker, 2020). To aid in management of acute angina the

addition of short acting nitrates is the first line therapy (Kannam, Aroetsy, & Gersh, 2021). The

optimal management of patients with angina requires more than antianginals to reduce the risk of

MI, stroke or death. Risk factor reduction includes antiplatelet, lipid lowering therapy and

lifestyle modifications (Kannam, Aroetsy, & Gersh, 2021). The patient is high risk for

cardiovascular events due to the progression of atherosclerosis, poor diet, smoking, alcohol

consumption and stress. The patient’s cholesterol is critical and must be addressed.

Nevertheless, the patient states he previously had issues with a statin, but before considering the

use of a second-line alternative drug it is appropriate to rechallenge statin therapy as in most

cases, rechallenging with a different or lower dose statin is successful (Alonso, Cuevas, &

Cafferata, 2019). Therefore, pravastatin 10 mg once daily at bedtime will be initiated due to it

being hydrophilic and is one of four statins recommended by the ACC/AHA 2018 guidelines for

patients who cannot tolerate moderate to high dose statins (Alonso, Cuevas, & Cafferata, 2019).

Nonpharmacologic Management:

Therapeutic lifestyle changes:

Encourage use of resources such as: American Heart Association’s lifes simple 7

(http://www.heart.org/en/healthy-living/healthy-lifestyle/my-life-check–lifes-simple-7)

Dietary Interventions: Encourage the Mediterranean and DASH diet

Limit saturated and trans-fat to 5-6% of calories and replace with healthier fats:

polyunsaturated and monounsaturated

Limit sodium to 2,400mg or less daily

Increase fruits and vegetables, whole grains, nuts/legumes, fish, and lean vegetable or animal

protein

Avoid red meat

Limit sugary drinks and sweets

Physical activity: 30 to 60 minutes of moderate intensity aerobic activity 5-7 days per week;

resistance training at least 2 days per week.

Smoking cessation

Health Promotion:

Per the USPSTF age is one of the most important risk factors for colorectal cancer recommends

screenings for colorectal cancer in all adults aged 50 to 75 with increased risks for African

Americans, men, and long-term smokers (USPSTF, 2021).

“The USPSTF recommends that clinicians ask all adults about tobacco use, advise them to stop

using tobacco, and provide behavioral interventions and US food and Drug Administration-

approved pharmacotherapy for cessations to nonpregnant adults who use tobacco” (USPSTF,

2021).

“The USPSTF recommends offering or referring adults with cardiovascular disease risk factor to

behavioral counseling interventions to promote a healthy diet and physical activity” (USPSTF,

2021).

“The USPSTF recommends screening for prediabetes and type 2 diabetes in adults aged 35 to 70

years who have overweight or obesity. Clinicians should offer or refer patients with prediabetes to

effective preventive interventions” (USPSTF, 2021).

“The USPSTF recommends 1- time screening for abdominal aortic aneurysm with ultrasound in

men aged 65 – 75 who have ever smoked” (USPSTF, 2021).

“The USPSTF recommends exercise interventions to prevent falls in community dwelling adults

65 years or older who are at increased risk for falls” (USPSTF, 2021).

“The USPSTF recommends screening for depression in the general adult population (USPSTF,

2021).

“The USPSTF recommends annual screenings for lung cancer with low-dose computed

tomography in adults aged 50 to 80 years who have a 20-pack year smoking history and currently

smoke or have quit within the past 15 years” (USPSTF, 2021).

Immunizations due: Influenza and Shingrix.

Patient education:

The patient and family will be educated on new medications and importance of compliance. An

in-depth discussion on benefits versus risk possible side effects/ complications; additionally,

what to expect for future appointments.

Smoking is a modifiable risk factor that increases risk to cardiovascular events. Cessation of

smoking is critical for the patient. We will discuss nonpharmacological management including

the patients’ personal willingness or concerns with quitting; especially weight gain as well as

triggers. Provide resources such as ACC decision pathway for tobacco cessation

http://www.onlinejacc.org/content/72/25/3332.

What is Angina?: High cholesterol causes the blockages or narrowing in the vessels. These

blockages or narrowing decrease blood which carries the oxygen our tissues need. Angina is

chest pain or discomfort due to lack of oxygen to the heart muscles when there is a blockage or

narrowing to the vessels of heart. Physical activity causes the heart to pump faster increasing

need for more oxygen but the blocked vessels decrease oxygen thus resulting in the pain.

Blockages or narrowing within the hearths vessels is known as coronary heart disease.

New medication Education:

Nitro SL: improve blood flow by relaxing and expanding veins and arteries. Sublingual or under

the tongue nitro is usually recommended to treat sudden attacks of angina and to prevent angina

while engaging in activities that typically trigger angina. Will effective within two to five

minutes and its effects last 15 to 30 minutes. You may repeat the dose of nitro for a total of two or

three doses five minutes apart before calling 911. If chest pain lasts more than five minutes after

taking up to three nitro pills, call 911 immediately.

Pills should be stored in a dark, tightly capped bottle in the refrigerator; you should carry a small

number with you at all times. An unopened nitroglycerin bottle is good for one year. The

combination of nitrates and medications for erectile dysfunction is particularly hazardous since the

combination may produce a severe decrease in blood pressure. Erectile dysfunction medications

must be avoided while taking a nitrate medication

Felodipine XR: This is a dihydropyridine calcium channel blockers and it works to dilate blood

vessels and slightly decrease the strength of the heart's contractions. Side effects include:

flushing, dizziness and lightheadedness, headache, and swelling of the feet and ankles please

report these symptoms. DO NOT CRUSH OR CHEW TABLETS. Take on an empty stomach

food will decrease level on drug available for your body to use. Do not consume grapefruit juice

while on medication it will cause serious interactions.

Aspirin: Heart attacks are usually the result of a blood clot forming inside a narrowed vessel of

the heart. Aspirin helps to prevent these clots from forming which lowers the risk of a heart

attack. Bleeding is the main side effect of aspirin, please report if you have very dark stools,

frequent nose bleeds, increased bruising or any other signs of bleeding.

Pravastatin: Due to history of dyslipidemia or “high cholesterol”, worsening bruits, decreased

color/hair to lower extremities and decreased peripheral pulses restarting a statin is appropriate.

Pravastatin helps lower blood levels of "bad" cholesterol (LDL), to increase levels of "good"

cholesterol (HDL), and to lower triglycerides – a type of fat in the blood. Reducing the

cholesterol lowers the risk of stroke, heart attack, and other heart complications. Avoid drinking

alcohol it can increase your risk of liver damage. Take medication at the same time every night.

Avoid grapefruit as it may interact with pravastatin and lead to unwanted side effects.

Pravastatin can rarely cause a condition that results in the breakdown of skeletal muscle tissue,

leading to kidney failure. Report symptoms of unexplained muscle pain, tenderness, or

weakness especially if you also have fever, unusual tiredness, yellowing of eyes, or dark colored

urine.

Disposition/follow-up instructions:

Follow up with cardiology within two weeks.

Patient is to monitor blood pressures at home and keep a log: Two readings 1 minute apart each

morning before medication and each evening before dinner.

Follow up in 4 weeks: Patient is to have labs repeated CMP, CBC and fasting lipids before

follow up appt. We will further discuss smoking cessation and steps if any were taken in the

past four weeks to effectively quit. I will then explore pharmacologic management with patient

pending willingness.

Patient will be further educated that people with angina have an increased risk for a heart attack,

cardiac arrest, and sudden cardiac death. Call an ambulance immediately if he experiences new,

worsening, or persistent pain or pressure in the center of the chest, shortness of breath, nausea,

vomiting, and pain that radiates from the chest into the teeth, jaws, shoulders, or arms.

Additionally, with new medications patient is to monitor for signs and symptoms of allergic

reactions that occur within an hour of taking medication including but not limited to fever, hives,

shortness of breath, sneezing, chest tightness, sudden cough, wheezing, swollen lips, tongue, eyes

or face. Call 911 or go to closest emergency room if this occurs.

Alonso, R., Cuevas, A., & Cafferata, A. (2019). Diagnosis and Management of Statin

Intolerance. Journal of atherosclerosis and thrombosis, 26(3), 207–215.

https://doi.org/10.5551/jat.RV17030

Gulati, M., Levy, P. D., Mukherjee, D., Amsterdam, E., Bhatt, D. L., Birtcher, K. K., . . . Shaw, L.

J. (2021). 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and

Diagnosis of Chest Pain: Executive Summary. Journal of the American College of

Cardiology, 78(22), 2218-2261. doi:10.1016/j.jacc.2021.07.052

Kannam, J., Aroetsy, J., & Gersh, B. (2021, June 3). Chronic coronary syndrome: Overview of

care. https://www.uptodate.com/contents/chronic-coronary-syndrome-overview-of-care?

search=angina&source=search_result&selectedTitle=2~150&usage_type=default&display_rank

=2

Orringer, C. E., Blaha, M. J., & Stone, N. J. (2021). Coronary artery calcium scoring in patients

with statin associated muscle symptoms: Prescribing statins for those most likely to

benefit. Journal of Clinical Lipidology, 15(6), 782–788.

https://doi.org/10.1016/j.jacl.2021.09.052

Rogers, J., & Baker, M. (2020). Understanding the most commonly billed diagnoses in primary

care: Atherosclerotic cardiovascular disease. The Nurse Practitioner, 45(7), 35.

https://doi.org/10.1097/01.NPR.0000669136.88720.65

U.S. Preventice Service Task Force. (2021).

https://www.uspreventiveservicestaskforce.org/uspstf/topic_search_results?topic_status=P

Williams, B., Mancia, G., Spiering, W., Agabiti Rosei, E., Azizi, M., Burnier, M., … &

Desormais, I. (2018). 2018 ESC/ESH Guidelines for the management of arterial hypertension:

The Task Force for the management of arterial hypertension of the European Society of

Cardiology (ESC) and the European Society of Hypertension (ESH). European heart journal,

39(33), 3021-3104.

188.0 pounds

Normal

Thyroid WNL to

palpation Full cervical

ROM

Carotid pulses normal and equal bilaterally; a faint right carotid bruit is

present Normal JVP; no HJR

PMI 5th ICS, medial to MCL

RR, rate 76 normal S1, S2; no

murmurs faint L femoral bruit is

present

Slight barrel

chested Clear to

auscultation

Sk i n / B re as t :

HEENT &

Neck:

C a r d i o va sc u l ar :

Respiratory:

Normal BS

Abdomen soft, nondistended, nontender

throughout No HSM, mass, or abnormal aortic

pulsation

Genitalia normal for stated

age No hernias seen

Normal

bulk

and

tone No

swollen

joints

CNII-XII grossly intact

Reflexes WNL

and symmetrical Normal Abd o men / G a s t r o i n t es t i n a l :

Gen i to ur i

nary:

M u sc u l o s ke l e t a l :

N e u r o l og i c a l :

A lle r g ic /

I m m u n o l o g i c :

No

adenopathy

No bruising

• Lipid Panel o Total Cholesterol = 230

mg/dL o HDL = 45 mg/dL

o LDL = 120 mg/dL

o TG = 175 mg/dL

Lym pha tic /

E n d o c r i n e :

Hemat ologic:

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