Lifestyle Issues in Cardiac Health
Angiogram Results
The angiogram shows complete obstruction of the first obtuse marginal artery and a high grade stenosis of the circumflex artery distal to the origin of the first obtuse marginal. Angioplasty and stent placement for each of these lesions is successful. Exhibit 3 shows an angiogram after treatment of the obtuse marginal lesion. Exhibit 4 shows an angiogram after treatment of the circumflex lesion.
Mr. Fowler tolerates the coronary catheterization well. His vital signs remain stable and his pain resolves. He is admitted to the coronary care unit for careful monitoring. Approximately 6 hours after his presentation to the emergency department, another EKG is obtained (Exhibit 5). At this time his serum CK is 586 U/L, CK-MB is 49.5 ng/ml and troponin I is 2.3 ng/ml.
The nitroglycerin infusion is discontinued. He is started on isosorbide dinitrate 20 mg po TID and metoprolol 25 mg po BID. He remains pain free. Blood pressure ranges from 115/70 mmHg to 132/86 mmHg and heart rate ranges from 65 to 85 per minute over the next 24 hours. On physical examination, his lungs remain clear and there is no heart murmur.
On the day following admission, heparin is discontinued, and he is started on enteric coated aspirin 325 mg/day. An echocardiogram shows an ejection fraction of 55% with trace mitral regurgitation. The atria and ventricles are of normal size.
Later that day, he is transferred to the regular ward. Over the next two days, his condition remains stable. He has no chest pain or shortness of breath. There is no evidence of arrhythmia or heart failure. A cardiac rehabilitation program is initiated.
Further history is obtained after admission to the hospital. Mr. Fowler reports that approximately a year ago he went through a difficult divorce and at that time started smoking again and abandoned his diet and regular exercise. Since then, he has smoked between one and two packs of cigarettes a day and estimates that he has gained approximately 20 pounds.
He has had a difficult time adjusting to living alone and has struggled to maintain relationships with his two adult children. He has also had considerable stress at work and feels that his job performance has been suboptimal. He has felt socially isolated and somewhat depressed.
He is discharged from the hospital four days after admission. At the time of discharge a fasting serum glucose is 115 mg/dL and fasting lipid profile consists of a total cholesterol of 216 mg/dL, triglycerides 150 mg/dL, HDL-cholesterol 32 mg/dL, LDL-cholesterol 154 mg/dL.
Questions
What is the appropriate management at the time of discharge?