NURS 6501 CARDIOVASCULAR AND RESPIRATORY DISORDERS MODULE 2 Scenario 1: Myocardial Infarction CC: “I woke up this morning at 6 a.m. with numbness in my left arm and pain in my chest. It feels tight right here (mid-sternal).” “My dad had a heart attack when he was 56-years-old and I am scared because I am 56-years-old.”

NURS 6501 CARDIOVASCULAR AND RESPIRATORY DISORDERS MODULE 2

Scenario 1: Myocardial Infarction

CC: “I woke up this morning at 6 a.m. with numbness in my left arm and pain in my chest. It feels tight right here (mid-sternal).” “My dad had a heart attack when he was 56-years-old and I am scared because I am 56-years-old.”

HPI: Patient is a 56-year-old Caucasian male who presents to Express Hospital Emergency Department with a chief complaint of chest pain that radiates down his left arm. He states this started this morning and has been getting worse, pointing to the mid-sternal area, “it feels like an elephant is sitting on my chest and having a hard time breathing”. He rates the pain as 9/10. Nothing has made the pain better or worse. He denies any previous episode of chest pain. Denies nausea, or lightheadedness. Nitroglycerin 0.4 mg tablet sublingual x 1 which decreased pain to 7/10.

Lipid panel reveals Total Cholesterol 424 mg/dl, high density lipoprotein (HDL) 26 mg/dl, Low Density Lipoprotein (LDL) 166 mg/dl, Triglycerides 702 mg/dl, Very Low-Density Lipoprotein (VLDL) 64 mg/dl

His diagnosis is an acute inferior wall myocardial infarction.

Question:

Which cholesterol is considered the “good” cholesterol and what does it do?

High-density lipoprotein (HDL) is also called the “good” cholesterol, while low-density lipoprotein (LDL) is called “bad” cholesterol. HDL absorbs cholesterol in the blood and transports it back to the liver. The liver then flushes the cholesterol from the body. High levels of HDL cholesterol lower the risk of heart disease and stroke. HDL has a diverse protein and lipid composition, contributing to its atheroprotective function (Jomard & Osto, 2020). In the vessel wall, HDL undergoes transcytosis through endothelial cells into the sub-endothelial space, where it efflux cholesterol from foam cells, preventing plaque formation. In addition, HDLs have other beneficial properties, like nitric oxide production stimulation, anti-oxidant capacity, anti-inflammatory, and anti-apoptotic actions.

Scenario 1: Myocardial Infarction

His diagnosis is an acute inferior wall myocardial infarction.

Question:

How does inflammation contribute to the development of atherosclerosis?

Atherosclerosis is a chronic inflammatory condition with an autoimmune component. It is accompanied by a chronic, low-grade inflammatory response that attracts cells of the innate and adaptive immune systems into the atherosclerotic plaque (Wolf & Ley, 2019). The autoimmune response is clinically best documented by antibodies against LDL and other atherosclerosis antigens. The continued development of atherosclerosis involves an inflammatory response, which begins with injury to the vascular endothelium. Inflammation has multiple effects on the arterial wall, including attracting inflammatory cells like macrophages (Jebari-Benslaiman et al., 2022). The macrophages infiltrate the injured vascular endothelium and ingest lipids, making them foam cells. Activated macrophages release biochemical substances that can further damage the endothelium, attracting platelets and initiating clotting.

Scenario 2: Pleural Friction Rub

A 35-year-old female with a positive history of systemic lupus erythematosus (SLE) presents to the Emergency Room (ER) with complaints of sharp retrosternal chest pain that worsens with deep breathing or lying down. She reports a 5-day history of low-grade fever, listlessness and says she feels like she had the flu. Physical exam reveals tachycardia and a pleural friction rub. She was diagnosed with acute pericarditis.