Comprehensive Management of Stable Angina in an Elderly Patient

This case study focuses on a 69-year-old female with a complex medical history, including obesity, coronary artery disease, and aortic stenosis, who presents with symptoms indicative of stable angina. Stable angina is usually caused by exertion and relieved by rest, which suggests that there is a mismatch of oxygen supply and demand in the myocardium. Management of this condition involves the administration of drugs intended for both relief of symptoms and prevention of acute flares on one hand and lifestyle modification for improving and controlling cardiovascular risk factors on the other hand. Although focusing on the factors that contribute to this index is important in managing symptoms, it is crucial to note that a comprehensive approach is equally important to enhancing overall cardiovascular health and the patient’s overall quality of life.

Case Description

For this case study, the patient is a 69-year-old female with a past medical history of obesity, coronary artery disease, and severe aortic stenosis who came in with complaints of typical stable angina. The chest pain started when the patient was slightly active,  but would ease after the affected person rested, as the other signs included dyspnea and extreme fatigue. The patient had no UPPER respiratory infection within the last two weeks or any other ACUTE illness within the last three months. The vitals suggested that the patient had mild tachycardia. Otherwise, the rest of the vitals readings were normal. History of prior grade II systolic murmur is well documented on auscultation, and no other abnormalities were observed. Thus, after assessing the clinical presentation and history, the patient was diagnosed with stable angina since the typical symptoms were manifested by chest pain during exercise and relief by resting.

Management Plan

The management plan for the patient with stable angina includes a comprehensive approach that integrates pharmacological treatments, non-pharmacological interventions, and necessary ancillary testing.

Pharmacological Treatments

The prescribed regimen involves a rational mix of medicines, such as beta-blockers, to minimize myocardial oxygen demand due to heart rate and contractility. Nitroglycerin was also used for the initial management of symptomatic relief of acute angina. To maintain her cholesterol levels and minimize the chances of atherosclerotic progression, a statin was initiated. Moreover, the use of an ACE inhibitor for the enhancement of vascular function and reduction in cardiovascular events is also prescribed alongside other therapeutic regimens for coronary artery disease (Farzam & Jan 2023).

Non-Pharmacological Interventions

            Lifestyle changes are an important part of the non-pharmacologic approach. The patient is counseled on a heart-healthy diet—one that is rich in fruits and vegetables, whole grains, and low in saturated fats and cholesterol (Ghodeshwar, 2023). Regular, moderate exercise as tolerated, such as brisk walking for 30 minutes most days, is recommended to achieve cardiovascular fitness. Smoking cessation and management of weight within normal limits are emphasized despite the fact that the patient presently does not smoke.

Ancillary Testing and Referrals

Given her very complex cardiac condition, she was booked for an echocardiogram to delineate cardiac function and structure, particularly the severity of aortic stenosis and myocardial performance (Kosaraju et al., 2021). Consultation with the cardiologist for ongoing management and a possible stress test to delineate the severity of ischemia in a controlled setting were also arranged.

Social Determinants of Health (SDOH), Health Promotion, and Risk Factors

It is evident that the patient’s ability to recover and overall health depend tremendously on multiple social factors. The scarcity of fresh and healthy food makes it more challenging to control her diet and keep her condition healthy for her heart. Also, her socioeconomic status may limit her access to the drugs required for the management of stable angina and routine medical check-ups (Whitman et al., 2022).

Health promotion strategies, hence, consist of teaching her about nutrition and exercise in consideration of her social and economic status. Local community services like food banks and community exercise programs can be used to help her adopt appropriate lifestyle changes at a low cost. Risk factors include physical and environmental changes and medical procedures, which must be combined by improving her support network to ensure she follows the management plan and actively engages in healthy activities recommended by her doctors. Providing the patient with transportation to other medical appointments and community support can also add to her care continuity and success.

Patient Education and Follow-Up

Concepts related to stable angina should be explained extensively to the patient, and emphasis placed on detecting symptoms and controlling risk factors. It was explained to the patient that nitroglycerin is used during an attack of acute angina and the necessity of taking the medicines as directed. Other strategies were described as other parts of her health plan, such as altering her diet and engaging in physical activities.

Follow-up appointments are scheduled every three months to monitor her condition. The patient was advised to seek immediate medical attention if she experiences increased frequency or severity of chest pain or symptoms unrelieved by rest or medication.

References

Farzam, K., & Jan, A. (2023, August 22). Beta Blockers. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK532906/

Ghodeshwar, G. K. (2023). Impact of lifestyle modifications on cardiovascular health: A narrative review. Cureus, 15(7). https://doi.org/10.7759/cureus.42616

Kosaraju, A., Muppidi, V., & Makaryus, A. N. (2021). Stress Echocardiography. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK448062/

Whitman, A., De Lew, N., Chappel, A., Aysola, V., Zuckerman, R., & Sommers, B. (2022). Addressing Social Determinants of Health: Examples of Successful Evidence-Based Strategies and Current Federal Efforts. https://aspe.hhs.gov/sites/default/files/documents/e2b650cd64cf84aae8ff0fae7474af82/SDOH-Evidence-Review.pdf

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Case

The patient is a 69 years old female with PHM of overweight BMI, CAD, HLD, and aortic stenosis presenting with intermittent, less than 5 minute episode of diffuse chest pain that began 5 days ago. Symptoms are worsened with mild exertion, relieved with rest within 3-5 minutes, and accompanied by dyspnea and fatigue on exertion. She denies tobacco, alcohol, and drug use as well as recent URI or viral illness, fever weight loss, nausea, vomiting. Vitals reveal mild tachycardia, but are otherwise stable, and physical exam shows pre-existing grade II systolic murmur without other abnormalities.

Assessment

• Intermittent chest pain
• Rest relieves symptoms
• Lack of Hypoxemia
• Exertion worsens symptoms
• Grade II murmur
• Tachycardic
• Overweight
• Unlabored Breathing
• No recent URI or viral illness
• Chest pain episodes <5 minutes
• Dyspnea
• Fatigue

Diagnosis: Stable Angina

Management Plan: Medications ordered (including over the counter) are appropriate, evidence based, written as a complete prescription, and includes appropriate medication education. Nonpharmacological treatment, additional ancillary testing and referrals ordered are appropriate. 20 points

All aspects of SDOH, health promotion and risk factors are addressed. 10 points

Patient Education: Comprehensive patient education is included related to current health visit. 10 points

Follow up instructions are complete and include time to next visit and specific symptoms to prompt a return visit sooner. 5 points

Contains parenthetical/in-text citations and at least 3 evidenced based references less than 5 years old are listed. Clinical practice guidelines are cited if applicable. 5 points