01 Jul 2009

Sample Essay: Cardiovascular Case Study

History and Patho-physiology: The focus of my case study is a 69 year old American, Victor Hartman who retired from IBM after a 30-year career in engineering; he wasn’t quite ready to settle into the typical, more relaxing retirement routine. Just one week after saying his goodbyes, he embarked on a fascinating journey to Hong Kong where he worked as a consultant for a Chinese firm for three years. Victor became healthier and got very fit in his new lifestyle where he walked a lot and was having active physical lifestyle. He says “Hong Kong is somewhat mountainous, and I did a lot of walking,” said Victor. “I could walk up hills that were over 60 stories high.””I went out to eat every day,” said Victor. “Even the fast food there is so much healthier than our fast food. You just don’t see overweight Chinese.” Victor returned to Rochester, Minn., in 1996 to begin the next phase of his retirement. Although home was comfortable and familiar, it did not automatically support a healthy lifestyle the way that Hong Kong had. Back in the United States, Victor no longer needed to walk to get where he wanted to go, and richer foods were convenient and plentiful. Not too surprisingly, Victor began to put on weight. “Then, one day, something happened,” said Victor. “All I did was run out to the mailbox, and when I was coming back, I blacked out.” After the blackout, Victor went to his doctor and learned he had coronary artery disease as well as high cholesterol. His doctor recommended further testing and treatment. He was diagnosed Victor with metabolic syndrome.

Diagnosis: “Metabolic syndrome” describes several conditions occurring together, such as increased blood pressure, elevated insulin levels, excess body fat around the waist or abnormal cholesterol levels. Having just one of these conditions increases risk for heart disease, stroke and diabetes, but in combination, the risk is even greater.”Metabolic syndrome is a lifestyle syndrome,” said Dr. Thomas. “The most effective treatment is when we can help patients identify and improve habits that improve their overall health. The good news is patients with this syndrome have an opportunity to take control, make changes and help prevent the development of more serious diseases.” Although metabolic syndrome has been known for years (in the past, it was usually referred to as insulin resistance syndrome or syndrome X) today it is becoming more prevalent.

Treatment: He joined the newly launched Cardiometabolic Program in early 2006 — one of the few in the nation. “It is a six-week program,” said Dr. Thomas. “People learn how to make changes in their behavior regarding nutrition and exercise, and in the process they reduce weight and learn how to manage the disorder.” The Cardiometabolic Program brings together a team of experts — from preventive cardiologists and registered dietitians, to exercise physiologists, and even behavioral medicine and sleep medicine specialists — to teach the skills necessary to make good choices and maintain long-term, healthy nutrition and exercise habits. (Chobanian 2560-2572)

The lifestyle changes were critical in his recovery plan; he needed to adopt a more active routine for maintaining his cardiac muscles. He was advised to take a 45 min. walk in his routine with dietary control and lifestyle changes. With the dietary and lifestyle changes, as well as changes in medications, Victor lost 30 pounds in five months, and lowered his cholesterol significantly. He believes the weight loss may have already helped prevent a more serious condition. He incorporated healthier portions in his meal like more fruit, less dairy and red meat portions.

Disease Factors and Symptoms: Cardiovascular disease is a wide-encompassing category that includes all conditions that affect the heart and the blood vessels. Cardiovascular disease is the number one cause of death in the United States. There are several diseases that have a role in the development of cardiovascular disease. Many risk factors are associated with cardiovascular disease; most can be managed, but some cannot. The aging process and hereditary predisposition are risk factors that cannot be altered. Until age 50, men are at greater risk than women of developing heart disease, though once a woman enters menopause, her risk triples.

Many people with cardiovascular disease have elevated or high cholesterol levels. Low HDL cholesterol (known as the “good” cholesterol) and high LDL cholesterol (known as the “bad” cholesterol) are more specifically linked to cardiovascular disease than is total cholesterol. A blood test, administered by most healthcare professionals, is used to determine cholesterol levels. Atherosclerosis (hardening of the arteries) of the vessels that supply the heart with blood is the most common cause of heart attacks. Atherosclerosis and high cholesterol usually occur together, though cholesterol levels can change quickly and atherosclerosis generally takes decades to develop. The link between high triglyceride levels and heart disease is not as well established as the link between high cholesterol and heart disease. According to some studies, a high triglyceride level is an independent risk factor for heart disease in some people. High homocysteine levels have been identified as an independent risk factor for heart disease. Homocysteine can be measured by a blood test that must be ordered by a healthcare professional. Hypertension (high blood pressure) is a major risk factor for cardiovascular disease, and the risk increases as blood pressure rises.6 Glucose intolerance and diabetes constitute separate risk factors for heart disease. Smoking increases the risk of heart disease caused by hypertension. Abdominal fat, or a “beer belly,” versus fat that accumulates on the hips, is associated with increased risk of cardiovascular disease and heart attack. Overweight individuals are more likely to have additional risk factors related to heart disease, specifically hypertension, high blood sugar levels, high cholesterol, high triglycerides, and diabetes. (Randomised 1383-1389)

People with cardiovascular disease may not have any symptoms, or they may experience difficulty in breathing during exertion or when lying down, fatigue, lightheadedness, dizziness, fainting, depression, memory problems, confusion, frequent waking during sleep, chest pain, an awareness of the heartbeat, sensations of fluttering or pounding in the chest, swelling around the ankles, or a large abdomen.

Dietary Changes: Preliminary evidence has linked high salt consumption with increased cardiovascular disease incidence and death among overweight, but not normal weight, people. Among overweight people, an increase in salt consumption of 2.3 grams per day was associated with a 32% increase in stroke incidence, an 89% increase in stroke mortality, a 44% increase in heart disease mortality, a 61% increase in cardiovascular disease mortality, and a 39% increase in death from all causes. Intervention trials are required to confirm these preliminary observations.

Moderate alcohol consumption appears protective against heart disease. However, regular, light alcohol consumption in men with established coronary heart disease is not associated with either benefit or deleterious effect.

A high intake of carotenoids from dietary sources has been shown to be protective against heart disease in several population-based studies. A diet high in fruits and vegetables, fiber, and possibly fish appears protective against heart disease, while a high intake of saturated fat (found in meat and dairy fat) and trans fatty acids (in margarine and processed foods containing hydrogenated vegetable oils) may contribute to heart disease. In a preliminary study, the total number of deaths from cardiovascular disease was significantly lower among men with high fruit consumption than among those with low fruit consumption. A large study of male healthcare professionals found that those men eating mostly a “prudent” diet (high in fruits, vegetables, legumes, whole grains, fish, and poultry) had a 30% lower risk of heart attacks compared with men who ate the fewest foods in the “prudent” category. By contrast, men who ate the highest percentage of their foods from the “typical American diet” category (high in red meat, processed meat, refined grains, sweets, and desserts) had a 64% increased risk of heart attack, compared with men who ate the fewest foods in that category. The various risks in this study were derived after controlling for all other beneficial or harmful influencing factors. A parallel study of female healthcare professionals showed a 15% reduction in cardiovascular risk for those women eating a diet high in fruits and vegetables-compared with those eating a diet low in fruits and vegetables. (Chobanian 2560-2572)

Age is the most significant risk factor for cardiovascular disease. The decreasing overall age-adjusted mortality reflects important advances in prevention and treatment of these common conditions. Through risk-factor assessment, early disease detection, and preventive strategies, the average age of AMI and heart failure patients has shifted about ten to fifteen years forward. Further, one-year AMI mortality (after reaching the hospital alive) has declined from 40 percent to 4-8 percent over the past twenty years. Similarly, one-year mortality of patients hospitalized for heart failure was halved from 50 percent to about 25 percent over that same period of time. The reduction in stroke mortality is less impressive, but there has been a marked drop in the incidence of stroke through drug treatment of hypertension and anticoagulation use for atrial fibrillation.

Medications: Statins. By blocking an enzyme in the formation of low-density lipoproteins (LDL), this class of drugs reduces levels of LDL in the blood and diminishes the accumulation of lipids in arteries. Statins may exert a beneficial effect by decreasing inflammation and oxidative stress, both of which contribute to AMI. Accordingly, these agents reduce acute infarction, recurrent minor infarction, heart failure, stroke, and even atherosclerotic disease of the leg and other arteries. First, large groups of patients with elevated LDL levels, with and without overt cardiovascular disease, were shown to benefit from the drug. Next, patients with atherosclerotic disease but with previously considered normal levels of LDL were shown to benefit by a reduction in recurrent cardiac events. This has led to a lowering and reclassification of “normal” and “ideal” values for LDL. Thus, more and more adults now have an “indication” for the long-term use of this medication class. ( Downs 1615-1622.)

Antihypertensive agents. Similar to the high cholesterol epidemic, large segments of the population have hypertension, a risk factor for AMI, stroke, heart and kidney failure, and likely sudden death. Safe agents that modify specific “drugable targets,” and thereby lower blood pressure, have emerged. Over time, newer agents have evolved that reduce morbidity and mortality similar to older antihypertensive, but with reduced or different side effects. Antihypertensive drugs include blockers of enzymes, receptors, or hormones and vascular channels such as angiotensin-converting enzyme (ACE) inhibitors, blockers of the adrenergic nervous system (beta and alpha adrenergic blockers), calcium-channel blockers, and angiotensin-receptor blockers (ARBs). When compared for relative efficacy in a recent clinical trial sponsored by the National Institutes of Health (NIH), these various agents were effective, but none more so than very inexpensive diuretic agents, which are now strongly recommended for routine initial use in hypertension. Unfortunately, most patients with hypertension require multiple antihypertensive drugs for optimal blood pressure control. As with the reduction in LDL targets over time, the “normal” and “ideal” values for blood pressure have been progressively lowered as data support the finding that such blood pressure reduction lowers the incidence of heart attack, stroke, heart and kidney failure, and sudden death. At least 30 percent of adults do not know that they have hypertension; of those who do, only 60 percent have blood pressures in these ideal zones. Therapeutic treatment of hypertension is one area where specific drugs are proving more or less efficacious in certain ethnic or demographic groups. This may explain why not all members of the population benefit similarly from the use of specific agents in a particular drug class. This observation has spawned the advent of ethnic and gene-specific therapy (pharmacogenetics). ( Downs 1615-1622.)

Thrombolytic agents. A major breakthrough that proved life-saving in the management of AMI was the advent of thrombolytic drugs and the use of aspirin. Thrombolytics dissolve clots in arteries, while aspirin prevents platelets from forming new clots. Several European studies initially identified an inexpensive, nonselective thrombolytic agent, streptokinase, as effective and generally safe for clot dissolution. A more directed drug, tissue-plasminogen activator (t-PA), which activates a specific protein target in the blood-clotting cascade, was tested in hopes that targeting a specific target would improve efficacy and safety over streptokinase. Such proved to be the case, but only by a relatively modest amount. ( Downs 1615-1622.)

Testing: Imaging techniques that have proved invaluable to assess cardiac functioning and structure noninvasively are echocardiography and studies using nuclear tracers. Echocardiography uses ultrasonic waves, which are delivered to the heart by a probe placed over the chest; the reverberations are recorded as images. The resultant information allows not only real-time pictures of the beating heart and valvular function but also information on blood flow and intracardiac pressures. Although neither echocardiography nor nuclear imaging is capable of visualizing the coronary arteries, nuclear testing allows relative estimations of the blood flow to the heart muscle, particularly segments served by specific coronary arteries. Stress testing has become valuable to screen for significant anatomic coronary artery disease. This allows the clinician to “sort out” chest pain or other symptoms such as shortness of breath and to assess the success or failure of bypass surgery or angioplasty/stent placement.

Work Cited

Chobanian , A.V. . “”The Seventh Report of the Joint National Committee on the Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 Report,” .” Journal of the American Medical Association no. 19 (2003):(Chobanian 2560-2572)

“Randomised Trial of Cholesterol Lowering in 4,444 Patients with Coronary Heart Disease: The Scandinavian Simvastatin Survival Study (4S),” Lancet 344, no. 8934 (1994): 1383-1389.

Downs , J.R.. “”Primary Prevention of Acute Coronary Events with Lovastatin in Men and Women with Average Cholesterol Levels: Results of AFCAPS/TexCAPS,” .” Journal of the American Medical Association 279 no. 20 (1998): 1615-1622

( Downs 1615-1622.)http://content.healthaffairs.org/cgi/ijlink?linkType=ABST&journalCode=jama&resid=279/20/1615

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