G.B., a 64-year-old farmer, is hospitalized for evaluation of chest pain. About 3 weeks PTA, he noted substernal chest pain brought on by lifting heavy objects or walking uphill. He describes a crushing or viselike pain that never occurs at rest, and is not associated with meals, emotional stress, or a particular time of day. When G.B. stops working the pain subsides in about 5 minutes.

G.B.’s mother and brother died of a heart attack at ages 64 and 59, respectively; his father, who is alive at age 86, has survived one heart attack and one stroke.

Family history (except for G.B.) is negative for DM. G.B. is 5’10” tall and weighs 235 lb; he drinks two to three beers a day and does not smoke or chew tobacco.

G.B.’s other medical problems include a 10-year history of HTN, and DM for 4 years. Until 3 weeks ago, G.B. could perform all his farm chores without difficulty, including heavy labor. He follows a no-added-salt diet, but consistently eats at fast-food establishments with his favorite meal consisting of two cheeseburgers and French fries.

G.B’s medication history reveals the following: lisinopril 10 mg PO once daily, metformin 500 mg  PO BID, and HCTZ 25 mg PO once daily. He rarely uses OTC meds. He has an allergy to sulfamethoxazole.

On admission to the cardiac ward, G.B. is in no apparent distress. Resting vital signs include supine BP 145/95 mm Hg (last ambulatory visit, 130/85 mm Hg), regular pulse, 84 B/P/M (last ambulatory visit 78 B/P/M), and RR 12 breaths/min. He has no peripheral edema or neck vein distension, and lung auscultation is WNL. Abdominal exam is unremarkable and he is A&O x 3. Cardiac auscultation reveals a regular rate &  rhythm with normal S1 and S2; third or fourth heart sounds and murmurs are not noted. A 12-lead ECG reveals NSR at a rate of 84 B/P/M without evidence of previous MI. All intervals are WNL.

Admitting Lab values include the following:

Hct, 43.5%

WBC, 5,000/µL

Sodium (Na),    140 mEq/L

Potassium (K),   4.7 mEq/L

Magnesium (Mg),  1.9 mEq/L

Random blood glucose,  132 mg/dL

Hgb A1C     7.4%

BUN, 27 mg/dL

Serum creatinine, 1.4 mg/dL

Urinary albumin-creatinine ratio,  27 mg/mmol

Chest radiograph is WNL

Q1: Assess G.B’s physical examination. What signs and symptoms are relevant to angina

Q2: What other objective diagnostic procedure/s will be helpful to confirm CAD & angina in G.B?

Q3: What independent risk factors for CAD are present in G.B? Which of these may be altered?

Q4: Are there any dietary patterns that G.B. can adopt that have demonstrated reductions in CV
end points?

Q5: Would you give G.B. a prescription for SL NTG on discharge from the hospital?

After having a positive treadmill stress test and undergoing subsequent cardiac catheterization,

G.B. is found to have two-vessel CAD with obstructive lesions of 55% and 70%, in the right coronary artery (RCA) and circumflex arteries, respectively. The LAD coronary artery is not involved.

 

Q6:  What is G.B.’s prognosis

This patient has non-modifiable risk factors, such as age over 55, male and significant family history of cardiovascular disease. The patient also has modifiable risk factors, such as hyperlipidemia, hypertension, DM, drinking alcohol, and unhealthy diet. However, the good news for Mr. G.B is that modifiable risk factors can be changed. Given patient history, he is an increased risk patient for developing MI or stroke, but if he adheres to the medications (SL NTG, statin, Aspirin, ACE inhibitors), and initiates lifestyle changes (avoid fatty & salty foods and alcohol products), then he has an overall good prognosis.

In general, prognosis of CAD depends on number of vessels affected and degree of dysfunction of the left ventricle. For this patient, I do not have the Echo result so I cannot determine the degree of left ventricular dysfunction to completely determine the patient’s prognosis. However, if we assume this patient has good left ventricular function, then with double vessel disease, he still has an excellent outlook for the next 5 years (1). Based on a journal from the European Journal of Cardio thoracic surgery, two vessels disease with preserved ventricular function has better prognosis then the three-vessel disease at 5 year follow up (2,3). If Mr. G.B fails to initiate heathy life style or adheres to medications, then invasive procedures should be applied to prevent worse prognosis.

 

Given G.B.’s active lifestyle and recent history of frequent anginal attacks, your team wishes to optimize chronic preventative therapy for chronic stable angina.G.B. currently is receiving metformin 500 mg PO BID, lisinopril 10 mg PO Once Daily, and HCTZ 25 mg PO Once Daily. His current resting HR and BP are 78 B/P/M and 135/90 mm Hg, respectively.

 

Q7: Is a β–blocker the best initial option for chronic stable angina in G.B?

β–blocker is the first line therapy for chronic stable angina as the treatment relieve anginal and prevent cardiovascular events (4). β–blocker is an excellent choice for exertional angina because it improves exercise tolerance by limiting heart response to exercise. β–blocker, such as metoprolol and atenolol are widely used to reduce angina on patient with preserved ventricular function (6). If the patient can not tolerate β–blocker or have insufficient control of symptoms, then calcium channel blocker can be also used. Even though β–blocker is used as first line therapy for chronic stable angina, it is well known to “reduce cardiovascular death and myocardial infarction by 30% in post-infarct patients but benefits in those with stable coronary artery disease are less certain (5)”.

 

G.B. is being discharged from the hospital today with prescriptions for SL NTG 0.4 mg tablets, metoprolol succinate 100 mg PO Once Daily, metformin 500 mg PO BID, and lisinopril 20 mg PO Once Daily, and education regarding diet and exercise.

Q8: Is there anything else G.B. should receive for his chronic stable angina?

 

The patient should be also placed on low-dose aspirin to reduce major cardiac events. Based on European society of Cardiology, “low dose aspirin reduces major cardiac events by up to 30% and should be prescribed to patients with coronary artery disease”. American Family Physician recommends aspirin as mainstay antiplatelet therapy for stable coronary artery patient (6).

Furthermore, the patient should be placed on statin therapy (high statin therapy: atorvastatin 40 mg) because it can slow the progression of coronary atherosclerosis (4). According to American Family Physician, all patients with established coronary artery disease should be on statin unless contraindicated (6). This patient is already on ACE inhibitors, which is also particularly beneficial for patients with stable angina with hypertension and diabetes.

 

 

 

G.B. returns to the hospital with recurrent angina 8 weeks after he was discharged. He mentioned he stopped his metoprolol 36 hours ago when he forgot to get his prescriptions refilled. He is transported to the hospital ED for treatment of angina unresponsive to 3 NTG tablets.

Q9: How could G.B.’s situation have been avoided?

The patient could have easily avoided the situation by filling the prescription and taking the metoprolol as prescribed. I believe if the patient was aware of the risk of missing dose of metoprolol for multiple days, then he would have been more active in refilling his prescription. Before discharging the patient, he should have received counseling on the importance of taking the medication on time in proper dosage. Also, patient should have been informed about the risks of missing the medication. If patient was aware of the risks, then he could have avoided missing the medication. In order to prevent similar events, patient’s family can be included in the treatment process and aid in patient in refilling the prescription. If family involvement is not an option, then a reminder on his phone or a call from pharmacy can be suggested. Additionally, he should have received instructions to follow up with his primary care provider.

 

Sources:

1. https://healthengine.com.au/info/coronary-heart-disease-chd
2. Neuza Helena Lopes, Felipe da Silva Paulitsch, Aécio F. Gois, Alexandre C. Pereira, Noedir A. Stolf, Luis Oliveira Dallan, José A.F. Ramires, Whady A. Hueb, Impact of number of vessels disease on outcome of patients with stable coronary artery disease: 5-year follow-up of the Medical, Angioplasty, and bypass Surgery Study (MASS), European Journal of Cardio-Thoracic Surgery, Volume 33, Issue 3, March 2008, Pages 349–354, https://doi.org/10.1016/j.ejcts.2007.11.025
3. Long-term outcome in double-vessel coronary artery disease in Japanese patients.
4. Wee, Y., Burns, K., & Bett, N. (2015). Medical management of chronic stable angina. Australian prescriber, 38(4), 131–136. https://doi.org/10.18773/austprescr.2015.042
5. 2013 ESC guidelines on the management of stable coronary artery disease: the Task Force on the management of stable coronary artery disease of the European Society of Cardiology.
6. ICHAEL M. BRAUN, DO, and WILLIAM A. STEVENS, MD, H. BARSTOW, MD, Womack Army Medical Center, Fort Bragg, North Carolina Am Fam Physician.2018 Mar 15;97(6):376-384.