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Substernal Chest Pain and Dyspnea in a Female Patient
The Journal for Nurse Practitioners 15 (2019) e65ee68
Contents lists available at ScienceDirect
The Journal for Nurse Practitioners journal homepage: www.npjournal.org
Case Challenge
Substernal Chest Pain and Dyspnea in a Female Patient Myriam Jean Cadet, PhD, FNP-C a b s t r a c t Keywords: acute coronary syndrome noneST-segment elevation myocardial infarction chest pain
A 76-year-old female patient presented to the emergency department with substernal chest pain and dyspnea symptoms. She reported that the symptoms started 2 days earlier. These symptoms can arise from both cardiac and noncardiac conditions. It is difficult to ascribe chest pain and dyspnea symptoms to a single cause. Recognizing these symptoms is critical for inpatient cardiac and primary care nurse practitioners to choose the correct diagnosis and facilitate more effective treatment planning. © 2018 Elsevier Inc. All rights reserved.
Substernal chest pain and dyspnea symptoms, which may be related to coronary heart disease, are common complaints in the emergency department.1 For example, the American Heart Association reported that coronary artery disease accounts for 1 in 7 deaths and kills more than 360,000 people a year in the United States.2 Also, similar chest pain and dyspnea symptoms can be associated with noncardiac pathology. Both symptoms may be difficult to evaluate clinically. Proper diagnoses are required to make timely decisions and are the cornerstone of successful treatment. This case challenge describes a female patient who presented with substernal chest pain and dyspnea symptoms for 2 days.
Medications: The medications that she currently takes are warfarin 10 mg by mouth daily, nitroglycerin 0.4 mg sublingual as needed, acetylsalicylic acid (ASA) 162 mg by mouth daily, and metformin 1000 mg one tablet by mouth twice daily. Social History: She denied the use of alcohol or tobacco. She was a smoker for 25 years and smoked 10 cigarettes per day. Family History: The patient reported that her family history includes DM, coronary artery disease, and HTN. Her 2 brothers died from myocardial infarction.
Case Presentation
Patient’s examination findings were as follows: Vital signs (V/S): blood pressure 160/100 mm Hg; pulse 112 beats/min; respiration 22 beats/min; pulse oximetry 93% on a 2-L nasal cannula; temperature 99 F; height 50 4; weight 180 lbs. General: alert and oriented; anxious; complaining of substernal chest pain and dyspnea; pain score 8/10. Head and neck: no jugular vein distention or thyroid enlargement. Cardiac: tachycardia (112 beats/min); heart sound normal (S1 and S2); no carotid bruit, fiction rubs, or murmur; bilateral lower extremities pitting edema þ1. Respiratory: bilateral lungs fields equal and clear; no tracheal shift. Abdomen: soft and nontender; normal bowel sound in all quadrants; no nausea, vomiting, or abdominal pain; spleen and liver nonpalpable. Genitourinary: no polyuria, dysuria, hematuria, or urinary incontinence.
Subjective Data Chief Complaint: A 76-year-old African American woman presented to the emergency department with complaints of severe substernal chest pain and discomfort at rest. The patient reported having throbbing chest pain for 2 days that sometimes woke her from sleep and lasted more than 15 minutes. She also reported shortness of breath and profuse sweating. The substernal chest pain radiated to her arms, left jaw, and neck. Medical History and Surgical History: Her medical history includes hypertension (HTN), atrial fibrillation, stable angina over the past 3 years with medical management, and diabetes mellitus (DM) type 2 over the past 7 years. She has no history of cardiac catheterization. Allergies: The patient is allergic to cephalosporin, which causes a rash.
https://doi.org/10.1016/j.nurpra.2018.11.001 1555-4155/© 2018 Elsevier Inc. All rights reserved.
Objective Data
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M.J. Cadet / The Journal for Nurse Practitioners 15 (2019) e65ee68
Case Study Questions 1. What differential diagnoses should be considered for the patient? 2. What diagnostic evaluations need to be performed? 3. What is the most likely diagnosis to be considered? 4. What is your proposed management for the patient? 5. What important patient education is required?
If you believe you know the answers to the following questions, then test yourself and refer to page e67 for the answers.
M.J. Cadet / The Journal for Nurse Practitioners 15 (2019) e65ee68
e67
Case Challenge
Substernal Chest Pain and Dyspnea in a Female Patient (continued from page e66) Case Challenge Questions and Answers
cTnC. The biomarkers cTnI and cTnT have better sensitivity and specificity than the cTnC biomarker.4
1. What Differential Diagnoses Should Be Considered for the Patient? The differential diagnoses of this patient could possibly include acute coronary syndrome (ACS), abdominal aortic aneurysm, pneumothorax, or pancreatitis, according to the American College of Cardiology/American Heart Association (ACC/AHA).3 ACS has a spectrum of clinical presentations that includes non-ST segment elevation myocardial infarction (STEMI), ST-segment elevation myocardial infarction (STEMI), or unstable angina. ACS is caused by a sudden imbalance of myocardial oxygen consumption and demand, which may lead to chest pain, dyspnea, and coronary artery obstruction.3 Another possible differential diagnosis may be abdominal aortic aneurysm (AAA). The abdominal examination did not reveal any back, groin, or abdominal pain; pulsatile abdominal mass; or pain during aortic palpation; therefore, AAA was ruled out. Also, an ultrasound may be needed to assist with the diagnosis of AAA. However, with a presentation of pneumothorax, a patient may have these signs and symptoms (ie, acute dyspnea, pleuritic chest pain, tachycardia, cyanosis, profuse diaphoresis, and decreased breath sounds). Likewise, a computed tomography scan may reveal atelectasis of the lung and possible hyperexpansion of ipsilateral hemithorax to rule in pneumothorax. Pancreatitis was also ruled out because of chest pain and dyspnea, confirmed on history and examination. A common sign of presentation is epigastric pain and elevated serum amylase and lipase tests, which may support the diagnosis of pancreatitis. Other differential diagnoses to rule out patient’s presentation included pneumonia, pulmonary embolism, aortic stenosis, and congestive heart failure (CHF). 2. What Diagnostic Evaluations Need to Be Performed? Electrocardiogram Because there was a concern of possible ACS, an electrocardiogram (ECG) was performed to determine the cause of the chest pain. The patient’s ECG rhythm shows new T-wave inversion in the lead II, small Q waves in leads III, and lead II ST depressions in V5 and V6. The results from the ECG implied coronary ischemia. ACC/ AHA’s guidelines recommend performing a 12-lead ECG within 10 minutes of a patient’s clinical presentation.3 An ECG rhythm helps differentiate stable angina, unstable angina, NSTEMI, or STEMI. Stable angina has a nonischemic ECG change; there is an absence of ST segment and T-wave abnormalities. Unstable angina may have the same ECG changes as NSTEMI, such as new T-wave inversion, transient ST elevation, or ST depression, but no increase of cardiac biomarkers. Persistent ST elevation, new bundle-branch block, or anterior ST depression is an indication of a true posterior MI.3 Cardiac Troponins The patient’s troponin I was elevated 5.96 ng/mL (normal range: 0e0.08 ng/mL); it is a vital test in the diagnosis of ACS. Troponins are the primary tests to rule out this condition.4 Elevated troponins can exclude other noncardiac conditions; they are clinically relevant to diagnose ACS. The cardiac troponins are cTnT, cTnI, and
Thrombolysis In Myocardial Infarction Risk Score The ACC/AHA3 recommends a validated tool, Thrombolysis In Myocardial Infarction (TIMI), to assess the risk of ACS. This tool is helpful in evaluating ACS; it predicts the prognosis for a patient’s condition and guides therapeutic care. A score of 0e1 indicates a low-risk score; a score of 6e7 indicates a very high risk. The TIMI risk score for the patient was 7; urgent revascularization was indicated to prevent cardiac ischemia. The risk score can be retrieved at https://www.mdcalc.com/timi-risk-score-ua-nstemi. Additional Diagnostic and Laboratory Testing ECG was considered due to the patient’s symptoms, past medical history, and physical exam, which were suggestive of CHF or valvular diseases. ECG may reveal abnormal systolic and diastolic function for CHF. A patient’s clinical diagnosis is supported by a chest x-ray, which may reveal infiltrate for pneumonia. Further, positive d-dimer testing may indicate pulmonary embolism. Another laboratory test B-type natriuretic peptide can help diagnose CHF. A BNP level >500 pg/mL is a significant result for CHF. An additional possible test to order is a complete blood count to rule out anemia (low mean corpuscular volume, hematocrit, and hemoglobin). 3. What Is the Most Likely Diagnosis to Be Considered? The most likely diagnosis for this patient is NSTEMI. The diagnosis of substernal chest pain and dyspnea encompasses several factors, such as ECG changes, laboratory results, patient’s medical history, clinical presentation, and abnormal vital signs. These factors help narrow down the differential diagnoses and point NPs toward an ACS diagnosis. The initial ECG and laboratory test results of this patient were abnormal. The ACC/AHA recommends performing an accurate clinical history and physical examination, interpreting ECG rhythms, and evaluating cardiac troponins for ACS patients.3 The patient presented with nonspecific symptoms of substernal chest pain and dyspnea that occurred at rest. She reported that the pain lasted more than 15 minutes and radiated to the arms, left jaw, and neck. These clinical presentations yield further clues to the probable underlying cause of NSTEMI condition. 4. What Is Your Proposed Management for the Patient? Vital Signs Monitor vital signs, including oxygen saturation to detect hypoxia.3,5 This patient presented with high blood pressure. Also, she had hypoxia (O2 saturation 93%), chest pain (score of 8/10), tachycardia, and tachypnea. Pharmacological Therapy Nitroglycerin: Nitroglycerin is a vasodilator used to treat ACS. It reduces ventricular wall tension and decreases cardiac preload.3 ACC/AHA recommends nitroglycerin 0.3e0.4 mg sublingual every 5 minutes for up to 3 doses for chest pain.3 Side effects are
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M.J. Cadet / The Journal for Nurse Practitioners 15 (2019) e65ee68
hypotension and headache.3 Nitroglycerin 0.3 mg sublingual for pain was given to the patient. Morphine sulfate: This is a potent analgesic often administered for chest pain. It produces anxiolytic effects, causes venodilation, and provides a reduction in pulse rates.3 Morphine therapy dose is 1e5 mg intravenous (IV); the treatment dose is repeated every 5e30 minutes to relieve chest pain.3 Frequent adverse effects are respiratory depression, constipation, hypotension, nausea, and vomiting. Administer naloxone (0.4e2.0 mg IV) for respiratory depression. The patient received 1 mg IV morphine sulfate. ASA: This antiplatelet therapy is used for ACS or following percutaneous coronary intervention (PCI).3 ASA may also be used to prevent stroke or stent thrombosis. The noneenteric-coated dosage is 75e325 mg daily; it is used for long-term maintenance therapy. Despite its benefits, it is contraindicated in gastrointestinal bleeding. The patient received 325 mg by mouth. Clopidogrel, Prasugrel, and Ticagrelor: These P2Y12 inhibitors are used as oral antiplatelet therapy. They inhibit platelet aggregation to prevent stents thrombosis or restenosis and ACS. Bleeding is a concern; discontinue any P2Y12 inhibitors approximately 5 days before surgery.3 Substitute a P2Y12 with ASA if any intolerance is observed.3 Dual antiplatelet therapy is needed to support reperfusion; an example of this is ASA (a loading dose of 325 mg) and the P2Y12 inhibitor clopidogrel (loading dose of 300 mg). Enoxaparin (1 mg/kg every 12 hours subcutaneously) was also administered to the patient.3 Clopidogrel is a well-established antiplatelet therapy for NSTEMI ACS. However, ticagrelor is recommended over clopidogrel for NSTEMI patients who undergo an early invasive or ischemiaguided strategy.3 Also, despite the increased risks of bleeding from clopidogrel, ASA, and warfarin, it is crucial to administer them to help prevent stent thrombosis. The patient’s INR (normal range 2.0e3.0) should also be monitored to avoid bleeding. Statins and Beta-Adrenergic Blockers: Statins are prescribed to prevent adverse cardiovascular events. The patient had atorvastatin 20 mg by mouth. Severe adverse reactions are rhabdomyolysis, myopathy, and hepatotoxicity. Beta-adrenergic blocker therapy also decreases blood pressure, heart contractibility, and heart rate.3 Contraindications are asthma, diabetic, and chronic obstructive pulmonary disorder; it may cause bronchospasm and hypoglycemia.3 Angiotensin-converting enzymes and angiotensin receptor blockers: These medications are prescribed for HTN, heart failure, DM, or chronic kidney disease.3 Renal function condition should be stabilized before starting an angiotensin-converting enzyme.3 Assess a patient’s creatinine level for potential renal impairment.3 PCI On the basis of the patient’s clinical presentation, ECG changes, and abnormal troponins results, a PCI was necessary to rule out this NSTEMI condition. PCI treats narrowing or blocked coronary arteries; it encompasses balloon angioplasty with or without implementation of stents to facilitate blood flow to cardiac muscles. If a patient presents with unstable angina, NSTEMI, or STEMI, a PCI
procedure may be necessary. Potential complications of the procedure include vascular complications, vasovagal reflex syndrome, or contrast-induced nephropathy. If these complications are left untreated, they can result in death.6 The PCI result for the patient revealed a 70% occlusion of the right coronary artery, for which a drug-eluting stent was inserted. She was transferred to the coronary care unit for recovery and discharged home 3 days later. 5. What Important Patient Education Is Required? Nurse practitioners are typically responsible for providing patient education after PCI. ACS patients require education regarding post-PCI care, cardiac rehabilitation, and lifestyle modification (including diet, exercise, smoking cessation, and medication management). This patient was diagnosed with NSTEMI ACS; therefore, 12 months of dual antiplatelet therapy was recommended due to the PCI procedure.3 The nurse practitioner’s role is to teach patients about dual antiplatelet therapy (eg, Plavix 75 mg daily or ticagrelor) in addition to aspirin (81 mg daily) to prevent further coronary occlusion. Conclusion Chest pain and dyspnea symptoms may be caused by cardiac and noncardiac conditions. In fact, if left untreated, severe complications and even death may occur. Prompt recognition of a patient’s presentation is crucial to ensure better health outcomes. Nurse practitioners need adequate knowledge and skills to identify and manage patients with chest pain to provide safe care. References 1. Marchick MR, Setteducato ML, Revenis JJ, et al. Comparison of 3 symptom classification methods to standardize the history component of the HEART score. Crit Pathw Cardiol. 2017;16(3):102-104. 2. American Heart Association. Cardiac rehabilitation: putting more patients on the road to recovery. Retrieved from http://www.heart.org/idc/groups/heart -public/@wcm/@adv/documents/downloadable/ucm_493752.pdf 3. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with noneST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;64(24):e139-e228. 4. Fathil MFM, Arshad MM, Gopinath SC, et al. Diagnostics on acute myocardial infarction: cardiac troponin biomarkers. Biosens Bioelectron. 2015;70:209-220. 5. Naidu SS, Aronow HD, Box LC, et al. SCAI expert consensus statement: 2016 best practices in the cardiac catheterization laboratory: (Endorsed by the cardiological society of India, and Sociedad Latino Americana de Cardiologia intervencionista; Affirmation of value by the Canadian Association of interventional cardiologyeAssociation Canadienne de Cardiologie intervention). Catheter Cardiovasc Interv. 2016;88(3):407-423. 6. Keeley EC, Vertilio MC. Radial artery access in women undergoing percutaneous coronary procedures. JACC Cardiovasc Intervent. 2015;8(4):513-514.
Myriam Jean Cadet, PhD, FNP-C, is an adjunct assistant professor at Lehman College, Bronx, New York, and can be reached at [email protected]. In compliance with national ethical guidelines, the author reports no relationships with business or industry that would pose a conflict of interest.
Contents lists available at ScienceDirect
The Journal for Nurse Practitioners journal homepage: www.npjournal.org
Case Challenge
Substernal Chest Pain and Dyspnea in a Female Patient Myriam Jean Cadet, PhD, FNP-C a b s t r a c t Keywords: acute coronary syndrome noneST-segment elevation myocardial infarction chest pain
A 76-year-old female patient presented to the emergency department with substernal chest pain and dyspnea symptoms. She reported that the symptoms started 2 days earlier. These symptoms can arise from both cardiac and noncardiac conditions. It is difficult to ascribe chest pain and dyspnea symptoms to a single cause. Recognizing these symptoms is critical for inpatient cardiac and primary care nurse practitioners to choose the correct diagnosis and facilitate more effective treatment planning. © 2018 Elsevier Inc. All rights reserved.
Substernal chest pain and dyspnea symptoms, which may be related to coronary heart disease, are common complaints in the emergency department.1 For example, the American Heart Association reported that coronary artery disease accounts for 1 in 7 deaths and kills more than 360,000 people a year in the United States.2 Also, similar chest pain and dyspnea symptoms can be associated with noncardiac pathology. Both symptoms may be difficult to evaluate clinically. Proper diagnoses are required to make timely decisions and are the cornerstone of successful treatment. This case challenge describes a female patient who presented with substernal chest pain and dyspnea symptoms for 2 days.
Medications: The medications that she currently takes are warfarin 10 mg by mouth daily, nitroglycerin 0.4 mg sublingual as needed, acetylsalicylic acid (ASA) 162 mg by mouth daily, and metformin 1000 mg one tablet by mouth twice daily. Social History: She denied the use of alcohol or tobacco. She was a smoker for 25 years and smoked 10 cigarettes per day. Family History: The patient reported that her family history includes DM, coronary artery disease, and HTN. Her 2 brothers died from myocardial infarction.
Case Presentation
Patient’s examination findings were as follows: Vital signs (V/S): blood pressure 160/100 mm Hg; pulse 112 beats/min; respiration 22 beats/min; pulse oximetry 93% on a 2-L nasal cannula; temperature 99 F; height 50 4; weight 180 lbs. General: alert and oriented; anxious; complaining of substernal chest pain and dyspnea; pain score 8/10. Head and neck: no jugular vein distention or thyroid enlargement. Cardiac: tachycardia (112 beats/min); heart sound normal (S1 and S2); no carotid bruit, fiction rubs, or murmur; bilateral lower extremities pitting edema þ1. Respiratory: bilateral lungs fields equal and clear; no tracheal shift. Abdomen: soft and nontender; normal bowel sound in all quadrants; no nausea, vomiting, or abdominal pain; spleen and liver nonpalpable. Genitourinary: no polyuria, dysuria, hematuria, or urinary incontinence.
Subjective Data Chief Complaint: A 76-year-old African American woman presented to the emergency department with complaints of severe substernal chest pain and discomfort at rest. The patient reported having throbbing chest pain for 2 days that sometimes woke her from sleep and lasted more than 15 minutes. She also reported shortness of breath and profuse sweating. The substernal chest pain radiated to her arms, left jaw, and neck. Medical History and Surgical History: Her medical history includes hypertension (HTN), atrial fibrillation, stable angina over the past 3 years with medical management, and diabetes mellitus (DM) type 2 over the past 7 years. She has no history of cardiac catheterization. Allergies: The patient is allergic to cephalosporin, which causes a rash.
https://doi.org/10.1016/j.nurpra.2018.11.001 1555-4155/© 2018 Elsevier Inc. All rights reserved.
Objective Data
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M.J. Cadet / The Journal for Nurse Practitioners 15 (2019) e65ee68
Case Study Questions 1. What differential diagnoses should be considered for the patient? 2. What diagnostic evaluations need to be performed? 3. What is the most likely diagnosis to be considered? 4. What is your proposed management for the patient? 5. What important patient education is required?
If you believe you know the answers to the following questions, then test yourself and refer to page e67 for the answers.
M.J. Cadet / The Journal for Nurse Practitioners 15 (2019) e65ee68
e67
Case Challenge
Substernal Chest Pain and Dyspnea in a Female Patient (continued from page e66) Case Challenge Questions and Answers
cTnC. The biomarkers cTnI and cTnT have better sensitivity and specificity than the cTnC biomarker.4
1. What Differential Diagnoses Should Be Considered for the Patient? The differential diagnoses of this patient could possibly include acute coronary syndrome (ACS), abdominal aortic aneurysm, pneumothorax, or pancreatitis, according to the American College of Cardiology/American Heart Association (ACC/AHA).3 ACS has a spectrum of clinical presentations that includes non-ST segment elevation myocardial infarction (STEMI), ST-segment elevation myocardial infarction (STEMI), or unstable angina. ACS is caused by a sudden imbalance of myocardial oxygen consumption and demand, which may lead to chest pain, dyspnea, and coronary artery obstruction.3 Another possible differential diagnosis may be abdominal aortic aneurysm (AAA). The abdominal examination did not reveal any back, groin, or abdominal pain; pulsatile abdominal mass; or pain during aortic palpation; therefore, AAA was ruled out. Also, an ultrasound may be needed to assist with the diagnosis of AAA. However, with a presentation of pneumothorax, a patient may have these signs and symptoms (ie, acute dyspnea, pleuritic chest pain, tachycardia, cyanosis, profuse diaphoresis, and decreased breath sounds). Likewise, a computed tomography scan may reveal atelectasis of the lung and possible hyperexpansion of ipsilateral hemithorax to rule in pneumothorax. Pancreatitis was also ruled out because of chest pain and dyspnea, confirmed on history and examination. A common sign of presentation is epigastric pain and elevated serum amylase and lipase tests, which may support the diagnosis of pancreatitis. Other differential diagnoses to rule out patient’s presentation included pneumonia, pulmonary embolism, aortic stenosis, and congestive heart failure (CHF). 2. What Diagnostic Evaluations Need to Be Performed? Electrocardiogram Because there was a concern of possible ACS, an electrocardiogram (ECG) was performed to determine the cause of the chest pain. The patient’s ECG rhythm shows new T-wave inversion in the lead II, small Q waves in leads III, and lead II ST depressions in V5 and V6. The results from the ECG implied coronary ischemia. ACC/ AHA’s guidelines recommend performing a 12-lead ECG within 10 minutes of a patient’s clinical presentation.3 An ECG rhythm helps differentiate stable angina, unstable angina, NSTEMI, or STEMI. Stable angina has a nonischemic ECG change; there is an absence of ST segment and T-wave abnormalities. Unstable angina may have the same ECG changes as NSTEMI, such as new T-wave inversion, transient ST elevation, or ST depression, but no increase of cardiac biomarkers. Persistent ST elevation, new bundle-branch block, or anterior ST depression is an indication of a true posterior MI.3 Cardiac Troponins The patient’s troponin I was elevated 5.96 ng/mL (normal range: 0e0.08 ng/mL); it is a vital test in the diagnosis of ACS. Troponins are the primary tests to rule out this condition.4 Elevated troponins can exclude other noncardiac conditions; they are clinically relevant to diagnose ACS. The cardiac troponins are cTnT, cTnI, and
Thrombolysis In Myocardial Infarction Risk Score The ACC/AHA3 recommends a validated tool, Thrombolysis In Myocardial Infarction (TIMI), to assess the risk of ACS. This tool is helpful in evaluating ACS; it predicts the prognosis for a patient’s condition and guides therapeutic care. A score of 0e1 indicates a low-risk score; a score of 6e7 indicates a very high risk. The TIMI risk score for the patient was 7; urgent revascularization was indicated to prevent cardiac ischemia. The risk score can be retrieved at https://www.mdcalc.com/timi-risk-score-ua-nstemi. Additional Diagnostic and Laboratory Testing ECG was considered due to the patient’s symptoms, past medical history, and physical exam, which were suggestive of CHF or valvular diseases. ECG may reveal abnormal systolic and diastolic function for CHF. A patient’s clinical diagnosis is supported by a chest x-ray, which may reveal infiltrate for pneumonia. Further, positive d-dimer testing may indicate pulmonary embolism. Another laboratory test B-type natriuretic peptide can help diagnose CHF. A BNP level >500 pg/mL is a significant result for CHF. An additional possible test to order is a complete blood count to rule out anemia (low mean corpuscular volume, hematocrit, and hemoglobin). 3. What Is the Most Likely Diagnosis to Be Considered? The most likely diagnosis for this patient is NSTEMI. The diagnosis of substernal chest pain and dyspnea encompasses several factors, such as ECG changes, laboratory results, patient’s medical history, clinical presentation, and abnormal vital signs. These factors help narrow down the differential diagnoses and point NPs toward an ACS diagnosis. The initial ECG and laboratory test results of this patient were abnormal. The ACC/AHA recommends performing an accurate clinical history and physical examination, interpreting ECG rhythms, and evaluating cardiac troponins for ACS patients.3 The patient presented with nonspecific symptoms of substernal chest pain and dyspnea that occurred at rest. She reported that the pain lasted more than 15 minutes and radiated to the arms, left jaw, and neck. These clinical presentations yield further clues to the probable underlying cause of NSTEMI condition. 4. What Is Your Proposed Management for the Patient? Vital Signs Monitor vital signs, including oxygen saturation to detect hypoxia.3,5 This patient presented with high blood pressure. Also, she had hypoxia (O2 saturation 93%), chest pain (score of 8/10), tachycardia, and tachypnea. Pharmacological Therapy Nitroglycerin: Nitroglycerin is a vasodilator used to treat ACS. It reduces ventricular wall tension and decreases cardiac preload.3 ACC/AHA recommends nitroglycerin 0.3e0.4 mg sublingual every 5 minutes for up to 3 doses for chest pain.3 Side effects are
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M.J. Cadet / The Journal for Nurse Practitioners 15 (2019) e65ee68
hypotension and headache.3 Nitroglycerin 0.3 mg sublingual for pain was given to the patient. Morphine sulfate: This is a potent analgesic often administered for chest pain. It produces anxiolytic effects, causes venodilation, and provides a reduction in pulse rates.3 Morphine therapy dose is 1e5 mg intravenous (IV); the treatment dose is repeated every 5e30 minutes to relieve chest pain.3 Frequent adverse effects are respiratory depression, constipation, hypotension, nausea, and vomiting. Administer naloxone (0.4e2.0 mg IV) for respiratory depression. The patient received 1 mg IV morphine sulfate. ASA: This antiplatelet therapy is used for ACS or following percutaneous coronary intervention (PCI).3 ASA may also be used to prevent stroke or stent thrombosis. The noneenteric-coated dosage is 75e325 mg daily; it is used for long-term maintenance therapy. Despite its benefits, it is contraindicated in gastrointestinal bleeding. The patient received 325 mg by mouth. Clopidogrel, Prasugrel, and Ticagrelor: These P2Y12 inhibitors are used as oral antiplatelet therapy. They inhibit platelet aggregation to prevent stents thrombosis or restenosis and ACS. Bleeding is a concern; discontinue any P2Y12 inhibitors approximately 5 days before surgery.3 Substitute a P2Y12 with ASA if any intolerance is observed.3 Dual antiplatelet therapy is needed to support reperfusion; an example of this is ASA (a loading dose of 325 mg) and the P2Y12 inhibitor clopidogrel (loading dose of 300 mg). Enoxaparin (1 mg/kg every 12 hours subcutaneously) was also administered to the patient.3 Clopidogrel is a well-established antiplatelet therapy for NSTEMI ACS. However, ticagrelor is recommended over clopidogrel for NSTEMI patients who undergo an early invasive or ischemiaguided strategy.3 Also, despite the increased risks of bleeding from clopidogrel, ASA, and warfarin, it is crucial to administer them to help prevent stent thrombosis. The patient’s INR (normal range 2.0e3.0) should also be monitored to avoid bleeding. Statins and Beta-Adrenergic Blockers: Statins are prescribed to prevent adverse cardiovascular events. The patient had atorvastatin 20 mg by mouth. Severe adverse reactions are rhabdomyolysis, myopathy, and hepatotoxicity. Beta-adrenergic blocker therapy also decreases blood pressure, heart contractibility, and heart rate.3 Contraindications are asthma, diabetic, and chronic obstructive pulmonary disorder; it may cause bronchospasm and hypoglycemia.3 Angiotensin-converting enzymes and angiotensin receptor blockers: These medications are prescribed for HTN, heart failure, DM, or chronic kidney disease.3 Renal function condition should be stabilized before starting an angiotensin-converting enzyme.3 Assess a patient’s creatinine level for potential renal impairment.3 PCI On the basis of the patient’s clinical presentation, ECG changes, and abnormal troponins results, a PCI was necessary to rule out this NSTEMI condition. PCI treats narrowing or blocked coronary arteries; it encompasses balloon angioplasty with or without implementation of stents to facilitate blood flow to cardiac muscles. If a patient presents with unstable angina, NSTEMI, or STEMI, a PCI
procedure may be necessary. Potential complications of the procedure include vascular complications, vasovagal reflex syndrome, or contrast-induced nephropathy. If these complications are left untreated, they can result in death.6 The PCI result for the patient revealed a 70% occlusion of the right coronary artery, for which a drug-eluting stent was inserted. She was transferred to the coronary care unit for recovery and discharged home 3 days later. 5. What Important Patient Education Is Required? Nurse practitioners are typically responsible for providing patient education after PCI. ACS patients require education regarding post-PCI care, cardiac rehabilitation, and lifestyle modification (including diet, exercise, smoking cessation, and medication management). This patient was diagnosed with NSTEMI ACS; therefore, 12 months of dual antiplatelet therapy was recommended due to the PCI procedure.3 The nurse practitioner’s role is to teach patients about dual antiplatelet therapy (eg, Plavix 75 mg daily or ticagrelor) in addition to aspirin (81 mg daily) to prevent further coronary occlusion. Conclusion Chest pain and dyspnea symptoms may be caused by cardiac and noncardiac conditions. In fact, if left untreated, severe complications and even death may occur. Prompt recognition of a patient’s presentation is crucial to ensure better health outcomes. Nurse practitioners need adequate knowledge and skills to identify and manage patients with chest pain to provide safe care. References 1. Marchick MR, Setteducato ML, Revenis JJ, et al. Comparison of 3 symptom classification methods to standardize the history component of the HEART score. Crit Pathw Cardiol. 2017;16(3):102-104. 2. American Heart Association. Cardiac rehabilitation: putting more patients on the road to recovery. Retrieved from http://www.heart.org/idc/groups/heart -public/@wcm/@adv/documents/downloadable/ucm_493752.pdf 3. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with noneST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;64(24):e139-e228. 4. Fathil MFM, Arshad MM, Gopinath SC, et al. Diagnostics on acute myocardial infarction: cardiac troponin biomarkers. Biosens Bioelectron. 2015;70:209-220. 5. Naidu SS, Aronow HD, Box LC, et al. SCAI expert consensus statement: 2016 best practices in the cardiac catheterization laboratory: (Endorsed by the cardiological society of India, and Sociedad Latino Americana de Cardiologia intervencionista; Affirmation of value by the Canadian Association of interventional cardiologyeAssociation Canadienne de Cardiologie intervention). Catheter Cardiovasc Interv. 2016;88(3):407-423. 6. Keeley EC, Vertilio MC. Radial artery access in women undergoing percutaneous coronary procedures. JACC Cardiovasc Intervent. 2015;8(4):513-514.
Myriam Jean Cadet, PhD, FNP-C, is an adjunct assistant professor at Lehman College, Bronx, New York, and can be reached at [email protected]. In compliance with national ethical guidelines, the author reports no relationships with business or industry that would pose a conflict of interest.