Pharmacotherapy Case Study 7: Ischemic Heart Disease (Stable Angina) By: Dr. Nehad Ahmed

 

Chief Complaint:

A 58-year-old male presents to the clinic with a 2-month history of intermittent chest pain. The pain is described as a pressure or tightness in the chest that occurs during physical exertion or emotional stress and typically resolves with rest. The patient reports that the pain has become more frequent over the past few weeks.

Subjective Data:

History of Present Illness (HPI):
The patient reports experiencing chest pain that is localized to the center of the chest and is described as a squeezing or pressure sensation. The pain occurs primarily during activities like walking briskly or climbing stairs and is relieved with rest after about 5-10 minutes. The chest pain has become more frequent in the past few weeks, occurring with less exertion. The patient denies any pain at rest or during sleep. There are no associated symptoms like shortness of breath, nausea, or diaphoresis during episodes of pain.

The patient states that the chest pain is similar to an episode that occurred 2 years ago, which resolved with rest and did not require hospitalization. The patient has had no recent episodes of severe chest pain, syncope, or palpitations.

Past Medical History (PMH):

Hypertension (diagnosed 10 years ago)

Hyperlipidemia (diagnosed 5 years ago)

Obesity (BMI 31 kg/m²)

Type 2 Diabetes Mellitus (diagnosed 7 years ago)

Smoking (1 pack/day for 30 years; quit 6 months ago)

No prior myocardial infarctions or known coronary artery disease (CAD) diagnoses.

Medications:

Amlodipine 5 mg daily

Atorvastatin 40 mg nightly

Metformin 500 mg twice daily

Aspirin 81 mg daily

Lisinopril 10 mg daily

Omeprazole 20 mg daily (for GERD)

Allergies:

No known drug allergies.

Family History:

Father had a myocardial infarction at age 60, history of hypertension.

Mother had type 2 diabetes and stroke at age 70.

Social History:

Former smoker (quit 6 months ago)

Occasional alcohol use (2-3 drinks per week)

Sedentary lifestyle, no regular exercise

Diet high in processed foods, low in fruits and vegetables

No significant psychosocial stressors

 

Review of Systems:

Cardiovascular: Chest pain on exertion, no pain at rest.

Respiratory: No shortness of breath, wheezing, or cough.

Gastrointestinal: No nausea, vomiting, or heartburn.

Endocrine: Stable blood glucose levels.

Neurological: No dizziness, syncope, or headaches.

Musculoskeletal: No joint pain or muscle weakness.

Objective Data:

Vital Signs upon Arrival:

Blood Pressure: 140/85 mmHg

Heart Rate: 78 bpm

Respiratory Rate: 16 breaths/min

Temperature: 36.8°C

Oxygen Saturation: 97% on room air

Weight: 95 kg (BMI 31 kg/m²)

Height: 175 cm

Physical Exam:

General: Overweight, alert, and oriented, no signs of acute distress.

Cardiovascular:

Regular rhythm, normal heart sounds, no murmurs or gallops.

No jugular venous distention (JVD).

Peripheral pulses intact.

Respiratory:

Clear lung fields bilaterally, no rales or wheezes.

Abdomen:

Soft, non-tender, no hepatomegaly.

Extremities:

No edema, cyanosis, or clubbing.

Mild bilateral lower leg swelling noted due to obesity.

Skin: Warm, no rashes or lesions.

Laboratory Results:

Electrolytes: Sodium 141 mEq/L, Potassium 4.1 mEq/L

Creatinine: 0.9 mg/dL (stable)

Blood Glucose: 110 mg/dL (fasting)

Hemoglobin A1c: 7.3%

Lipid Profile:

Total Cholesterol: 220 mg/dL

LDL: 130 mg/dL

HDL: 38 mg/dL

Triglycerides: 170 mg/dL

High-sensitivity C-Reactive Protein (hs-CRP): 3.2 mg/L (elevated)

Electrocardiogram (ECG):

Sinus rhythm, heart rate of 78 bpm, no significant ST-T wave changes.

No evidence of ischemia or arrhythmias at rest.

Stress Test (Exercise Treadmill Test):

The patient was able to exercise for 6 minutes without chest pain or significant ECG changes.

Mild ST depression noted during the final stage of exercise, which resolves with rest. This suggests possible ischemia on exercise.

Echocardiogram:

Normal left ventricular ejection fraction (LVEF 60%)

No significant valvular disease.

Mild concentric left ventricular hypertrophy, likely due to long-standing hypertension.

Assessment:

The patient is presenting with stable angina, likely due to ischemic heart disease (IHD). The patient’s chest pain is consistent with stable angina, occurring during physical exertion or emotional stress and relieved with rest. The patient has several risk factors for coronary artery disease (CAD), including hypertension, hyperlipidemia, obesity, type 2 diabetes, and a family history of heart disease.

The stress test is suggestive of possible ischemia, as evidenced by mild ST depression during exercise, which typically resolves with rest.

Risk factors such as elevated LDL, smoking history, obesity, and family history of early coronary artery disease significantly increase the likelihood of coronary artery disease and ischemia.

ECG at rest shows no acute changes, which is consistent with stable angina rather than an active myocardial infarction.

Lipid profile is suboptimal, with elevated LDL levels, which should be addressed as part of the management of ischemic heart disease.

Plan:

Pharmacotherapy:

Nitroglycerin (sublingual 0.3–0.6 mg as needed) for chest pain relief during episodes.

Aspirin 81 mg daily to reduce the risk of thrombotic events.

Beta-blocker: Initiate metoprolol succinate 25 mg daily to reduce heart rate, blood pressure, and myocardial oxygen demand. This will also help control angina symptoms.

Statin therapy: Continue atorvastatin 40 mg nightly to manage cholesterol and reduce cardiovascular risk. Goal is to achieve an LDL <100 mg/dL.

ACE Inhibitor: Continue lisinopril 10 mg daily for blood pressure control and heart protection.

Antihypertensive therapy: Continue amlodipine 5 mg daily to control blood pressure, especially considering the patient’s history of hypertension.

 

 

Lifestyle Modifications:

Diet: Encourage a heart-healthy diet, including the DASH diet (low in sodium, rich in fruits, vegetables, and whole grains).

Exercise: Gradual increase in physical activity (e.g., 30 minutes of walking 5 days a week) as tolerated. Cardiac rehabilitation referral if needed.

Weight loss: Advise the patient to lose weight (target BMI <25) to improve overall cardiovascular health.

Smoking cessation: Reinforce the importance of not smoking and continued avoidance of tobacco products.

Monitoring:

Blood pressure: Goal <130/80 mmHg.

Lipid profile: Recheck in 3 months to assess response to statin therapy.

Blood glucose: Regular monitoring of blood glucose and HbA1c to ensure good diabetes control (goal HbA1c <7%).

ECG: Follow-up in 6 months or sooner if symptoms worsen.

Exercise tolerance: Reassess with another stress test in 6 months to monitor progression of ischemia.

Patient Education:

Angina management: Educate the patient on how to use nitroglycerin for chest pain episodes and when to seek medical attention if pain is not relieved.

Medication adherence: Emphasize the importance of taking all prescribed medications consistently, including beta-blockers, statins, and aspirin.

Heart disease risk reduction: Provide educational materials on lifestyle changes to reduce risk factors for further ischemic events, including smoking cessation, weight loss, and improved physical activity.

Follow-up:

Follow-up appointment in 3 months for reassessment of symptoms, medications, and lab work.

Return sooner if there are any concerns such as increased chest pain, shortness of breath, or changes in exercise tolerance.

Discussion:

Stable angina, a form of ischemic heart disease, is characterized by predictable chest pain triggered by physical exertion or stress. The underlying cause is typically atherosclerotic plaque formation that narrows coronary arteries, reducing blood flow to the heart. The patient in this case has several risk factors that contribute to the development of coronary artery disease, including hypertension, hyperlipidemia, diabetes, and obesity. Management of stable angina involves both pharmacotherapy to relieve symptoms and reduce the risk of progression, as well as lifestyle changes to modify risk factors.

Beta-blockers, nitroglycerin, statins, and aspirin are key components of the pharmacological treatment plan. A careful balance of controlling blood pressure, reducing cholesterol, and preventing thrombotic events can significantly reduce the risk of myocardial infarction and improve quality of life for patients with ischemic heart disease.

Prognosis:
With proper medication adherence, lifestyle modifications, and regular monitoring, the patient’s risk of future cardiovascular events can be significantly reduced. Continued management of risk factors, including blood pressure, cholesterol, and blood glucose, will be crucial in preventing disease progression.