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Question about hypertension, coronary artery disease, ECG reports and atherosclerosis?

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General & Family Physician
Practicing since : 2005
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1. Mr. T., a 45-year-old black male employed as a midlevel corporate manager was seeking a physical examination. He appeared somewhat overweight. He denied taking any medications or smoking, but admitted drinking alcohol. His father and older brother have hypertension, and his paternal grandfather experienced an MI and a CVA at a young age. Mr. T. stated, “A year ago at a health fair, my cholesterol was tested. I was told later by mail that my cholesterol was 250.”

What lab tests are indicated? What other questions should be asked of this patient? What are Mr. T’s risk factors for hypertension and coronary artery disease? If Mr. T. showed a high level of intellectual curiosity, and kept asking questions, how would you explain the pathophysiology of hypertension and coronary artery disease to him?

2. Dr. L., chief of surgery at a local hospital, was dressing for a dinner party at his home some two hours before guests were expected. His wife had been planning the event for several weeks, and she had made it clear she wanted everything to be “perfect” for her guests, who were mostly women from a museum board on which she was a member and their husbands, people with whom Dr. L. felt he had little in common. He was feeling somewhat irritable and restless as he dressed, and noticed he was breathing slightly faster than usual, and had drops of sweat forming on his forehead. He at first attributed this to anticipation of the evening’s stress, as he dreaded trying to appear interested in contemporary art, which he mostly consider worthless trash, but as the symptoms lasted for nearly two hours, he began to wonder if something more serious might be involved. He went to find his wife, whose eyes widened on seeing him. “Are you all right?” she asked with concern in her voice. Dr. L then tried to consider the situation professionally, and decided he should at least have his blood pressure checked, but while he considered whom he could ask to check it, his wife called 911. On arrival at the ED, blood was drawn, and the lab report showed elevated troponin levels.

What kinds of changes in this patient’s ECG? Will the delay in recognizing the symptoms have consequences in the pathological changes in his heart? Is this presentation very unusual? What are the likely consequences to the myocardium from this sort of event?

3. A 46-year-old woman reports weakness, fatigue, and occasional palpitations. She says her doctor told her she has an enlarged heart. What is the more technical description of her condition? What are the possible causes of her condition? Please describe the pathophysiology behind the development of this condition. What is the likely endpoint of the disease?

4. A 48-year-old science instructor signed up for a Health Fair at work at which he was weighed and measured, had his blood pressure, glucose, and cholesterol levels checked. He was found to be 5 feet 4 inches tall, weighed 164 pounds, had a fasting glucose of 100 mg/dL, and a cholesterol level of 248 mg/dL. His field of expertise was chemistry, but he asked about atherosclerosis. How would you explain the pathophysiology of atherosclerosis to him? That is, how does atherosclerosis develop? What are the consequences of atherosclerosis? How can he minimize risk for adverse consequences? What are his major risk factors?

5. A 38-year-old man complains of swollen ankles and pain. He denies any history of injury. On exam, he is found to have edema and darkening of the skin around his ankle, foot, and lower leg. He is very tender around the medial malleolus as well. What are the possible diagnoses for this patient? What is the pathophysiology behind these conditions? How should he be treated? What are the serious risks from this condition?
Posted Thu, 26 Apr 2012 in Hypertension and Heart Disease
Answered by Dr. Prasad 33 hours later

Thanks for the query.

I understand that you are looking for answers to some of the cardiovascular conditions. As a clinician, I would be able to answer your queries. Details of pathophysiology can be answered very well by a pathologist. And as no pathologist have picked your question (which usually doesn't happen in this forum), I shall take this opportunity to answer your queries here.

The first case history describes an individual at moderate risk to develop cardiovascular complication. Though the history is clear, I would like to know if he has history of diabetes and hypertension. I would also like to know if he has indigestion, abdominal pain, chest pain, breathing difficulties in the past. As far as lab tests are considered, blood pressure check up, blood samples to test blood sugar (fasting as well as post prandial sugars), liver function, recent fasting lipid profile, liver function tests, ECG and Ultrasound abdomen would be the initial line of investigations.
It would be hard to explain the pathophysiological changes here. Hypertension and coronary artery disease (CAD) is a condition that is related to genetics, diet and lifestyle. Apart from these 3 factors, blood sugars, cholesterol and co existent systemic illness have impact on the pathophysiology of hypertension and CAD. To briefly explain blood pressure is influenced by pumping of the heart (cardiac output) as well as hardening / narrowing of the blood vessels (peripheral resistance). Ideal cardiac output and peripheral resistance is essential to maintain normal blood pressure. As and when either of these 2 factors is increased, blood pressure rises and hypertension develops. CAD is more related to the peripheral resistance / obstruction in the coronary arteries in particular. Obstruction and reduced blood flow of the coronary arteries lowers oxygenation to the cardiac muscles resulting in ischemia. This is the basis for the development of CAD. The amount of ischemia is directly proportional to the percentage of obstruction; accordingly are the severity of presenting complaints – angina to myocardial infarction.

The second case seems like an ongoing myocardial infarction. Typically ECG in myocardial infarction has ST segment elevation. Sometimes there could be other changes too. If my guess is right, his ECG should have shown ST segment elevation in any of the ECG leads. Though the presentation is not typical ( a typical patient would have more of chest pain) symptoms of sudden onset irritability, restlessness, perspiration can be the only symptoms in this event especially if the patient also has blood sugars that are not very well controlled. It would have been better if you could have mentioned his diabetes history if any. It is also very well known that the amount of damage on the cardiac muscles (myocardium) and thus the prognosis depend on the time of onset. We have lost quite a few patients due to delay in treatment. It is very important to recognize such events earlier. Delay in the treatment will result in more ischemic events and the percentage of myocardial death.

You have mentioned about enlarged heart with weakness, fatigue and palpitations in a 46 year woman in the third clinical summary. Enlarged heart is medically referred to as cardiomegaly. There are numerous conditions that cause cardiomegaly. The commonest are anemia, thyroid problems, valvular diseases, certain drugs, hormonal problems and so on. Proper history, detailed examination and further lab tests will help in ruling the causes. Pathologically the condition occur either due to dilatation of the myometrium or obstructive causes. They are further influenced by blood pressure, high out state, stroke volume of the heart, myometrium musculature. The condition is likely to end in cardiac failure.

The fourth summary is about atherosclerosis. Atherosclerosis refers to hardening of arteries. This occurs due to accumulation of plaques within the lumen of the blood vessels. The plaques normally are made up of lipids, few blood cells and other inflammatory cells. Out of these lipids are the most important constituents which get deposited at certain places in the blood vessel. These deposits attract certain blood cells, inflammatory cells and other blood cells to form a plaque. These plaque deposits can produce inflammatory changes that results in the hardening of arteries. Both the hardened arteries and the plaques within the lumen results in narrowing and occlusion of blood flow resulting in complications
The most common sites to find atherosclerosis are large arteries. These changes are usually the causes of heart ischemia (angina / myocardial infarction), strokes, renal artery diseases, peripheral vascular disease, gangrene and so on.
It is most important to keep cholesterol and lipid levels under normal limits to minimize the risk of atherosclerosis. In addition blood pressures, blood sugars can also influence the risk of atherosclerosis. Hence diet and lifestyle changes are most important prophylactic measures to prevent atherosclerosis.

The last question is not completely clear. Swelling and pain with tenderness restricted to the ankle joints are usually due to joint pathology such as arthritis. However in the presence of pedal oedema, darkening of extremities peripheral vascular disease such as Thromboangiitis obliterans (TAO) needs to be ruled out. These 2 will be my important differential diagnosis based on the history given. In addition, I would also rule out fractures though he denies history of injuries.
Since I consider peripheral vascular disease as the most likely cause, I shall explain more about this alone.
Peripheral vascular disease is commonly associated with atherosclerosis of the arteries of limbs. In other times, it is caused due to thrombus formation or embolisms from a different source. There is occlusion of blood flow due to narrow arteries. This results in ischemic changes which gradually progress to form gangrene. The condition can be treated if there is no complete gangrene formation. The condition can be treated medically with anticoagulants. Surgical treatment may be sometimes needed to reverse the condition. Limb should be amputated to reduce the morbidity if gangrenous changes occur. So it is important to treat the condition to prevent gangrene and subsequent loss of limb.

Hope I have answered your query. Please accept my answer in case you do not have further queries.

Best wishes.
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