Read through the following clinical vignettes and take time to review each woman's cardiovascular risk factor profile. Then, refer to the questions at the end of the case study to analyze each female patient's current health status.

In analyzing these clinical vignettes, consider the following questions:

Patient M is a White woman, 75 years of age, who presented to her local emergency department with sudden complaints of chest pain. She described the pain as a severe substernal burning sensation that radiated across the chest to her shoulders bilaterally and then to the neck and jaw region. Although not brought on by exertion, the chest pain was associated with dyspnea, pallor, diaphoresis, nausea, and epigastric discomfort. Patient M had taken one nitroglycerin tablet with partial relief. When the chest pain recurred 10 to 15 minutes later, her family dialed 911 and the local emergency medical service responded. Once transported to the emergency department, her pain persisted. She received two additional doses of nitroglycerin and was placed on 2 L of oxygen per nasal cannula.

Following stabilization, she was admitted to a telemetry floor for further observation and medical management. Nursing assessment revealed the following cardiovascular risk factors: 50-pack-year history of smoking, hypertension, and mild-to-moderate obesity. As part of the medical workup, Patient M was scheduled for a coronary angiogram the following day. The angiogram revealed an 80% blockage of the right coronary artery and the cardiologist recommended Patient M consider a PCI to open the coronary artery blockage.

The following day, Patient M underwent a PCI to the right coronary artery. The procedure was progressing uneventfully until she had an episode of bradycardia as her heart rate dropped to 38 beats per minute. The patient received a 0.5 mg dose of IV atropine, which was repeated in 10 minutes. Other than this episode, Patient M did not experience any other postprocedure complications, such as hypotension, or other technical-related problems.

The day after the PCI, Patient M was receiving her discharge instructions from her nurse when she began noticing a return of the dull epigastric pain. The pain did not appear to be related to her food intake because she was progressing on her diet. Later that day, as the pain persisted, Patient M had an ultrasound of her abdomen, which showed multiple walnut-sized gallstones. The gastroenterologist referred her to a general surgeon who recommended that she undergo a cholecystectomy for further relief of her gastrointestinal symptoms. The surgeon advised her of the risks and benefits of laparoscopic versus traditional surgery, and Patient M opted for the laparoscopic procedure. Four small incisions were made in her abdomen, and the cholecystectomy was performed without any complications. Three days postoperatively, she complained again of moderate-to-severe epigastric pain and became jaundiced. An endoscopic retrograde cholangiopancreatography revealed retained stones in the common bile duct, which were removed. Patient M subsequently recovered and was discharged home after a total of nine days in the hospital.

In analyzing this case study, consider the following questions:

Patient Y, a woman 76 years of age, was seen in the Women's Cardiac Center for a personalized health and risk factor assessment. Assessment findings included a heart rate of 84 beats per minute, blood pressure 172/68 mm Hg, height 5'5", and weight 171 pounds. Waist-hip ratio was 0.75, and skin fold calipers measured 42% body fat. Lipid profile included total cholesterol of 239 mg/dL, HDL 40 mg/dL, LDL 159 mg/dL, ratio 5.9 mg/dL, and triglycerides 248 mg/dL. Fasting glucose was 79 mg/dL. Past medical history included hiatal hernia, cholecystectomy, hypothyroidism, arthritis, insomnia, and a long-standing history of ankle edema. The patient also reported symptoms suspicious of sleep apnea.

Based on this assessment, cardiovascular risk factors were identified and the patient was instructed on risk factor modification. Four months later, she phoned the Women's Cardiac Center with complaints of anterior chest discomfort that radiated to her neck, jaw, and back, accompanied by shortness of breath. She was referred to Cardiology and seen three days later.

The diagnostic workup included a 12-lead ECG and nuclear myocardial perfusion scan, followed by an angiogram. She was not considered a candidate for the exercise EKG due to her advanced age and other comorbidities, specifically arthritis, which would limit her ability to exercise at adequate intensity levels. The 12-lead ECG revealed nonspecific T-wave changes in the inferior leads, and the nuclear scan was positive, suggestive of single-vessel disease of the left circumflex artery. An angiogram was then performed and showed triple vessel disease with significant left main disease. Her occlusions were 50% to 60% of the left main, 90% of the circumflex, and 60% of the right coronary artery. EF was estimated at 60%, indicating preserved left ventricular function. Based on these diagnostic findings, the patient was referred for CABG surgery.

Two weeks later, Patient Y underwent CABG surgery with internal mammary grafting. During surgery, she required inotropic support with dobutamine and epinephrine and atrioventricular sequential pacing. An intra-aortic balloon pump (IABP) was also placed via the right femoral artery due to right heart failure. On the first postoperative day, the patient remained in the intensive care unit on the IABP and ventilator. Lab values showed a creatine phosphokinase of 3113 IU/L and creatine kinase isoenzyme MB of 169.4 IU/L. A bedside echocardiogram confirmed an inferior-posterior and right ventricular infarct.

The patient was transferred to the cardiac surgical stepdown unit on the third postoperative day where she developed atrial fibrillation and was digitalized. Oxygen was administered at 5 L per nasal cannula and her ambulation was significantly limited. In addition, a bruit was noted in her right groin. An echo-Doppler revealed a two-chamber pseudoaneurysm which was unsuccessfully compressed. On the sixth postoperative day, the patient went in and out of atrial fibrillation/flutter and converted to sinus rhythm on postoperative day 7. As a result, she was weaned from oxygen and progressed with independent ambulation. However, she remained hospitalized until postoperative day 12 for observation of her heart rhythm and right groin pseudoaneurysm.

Two days after discharge, the patient received a follow-up telephone call from the Cardiac Liaison Nurse to assess her condition. Patient Y stated she was "feeling pretty good," yet indicated some difficulty with incisional pain, anorexia, fluid loss, insomnia, and confusion about her medications. After recuperating at home, the patient enrolled in a phase II cardiac rehabilitation program. At this time, the patient reports no angina or chest discomfort. She is progressing in her exercise program and tolerating activity. Problems experienced since discharge include a urinary tract infection, depression, and increasing heart failure. Her furosemide dosage has been increased, and she has obtained good relief of her symptoms.

In analyzing this case study, consider the following questions:

Patient A was a woman, 88 years of age, who lived in an assisted living retirement home. She had been a widow for 20 years, after losing her husband to long-term complications associated with diabetes. Until approximately seven years ago, Patient A had been in relatively good health with no major health problems, but she suffered a mild stroke at 81 years of age. At that time, she decided to quit her 50- to 60-year smoking habit. Other than her smoking history, she did not have any other significant cardiovascular risk factors.

After recuperating from her stroke, Patient A decided to leave her apartment and move into the assisted living facility where she would not only have some companionship but also receive assistance with meals and transportation to doctor's appointments and other activities. About six years after suffering the cerebrovascular accident, she had a bout of heart failure. She was admitted to the local hospital and received oxygen per nasal cannula, IV furosemide, and digoxin. After two weeks in the hospital, the patient was discharged home in apparently better condition. However, two days after returning home Patient A suffered a sudden cardiac death event at the breakfast table. Efforts at resuscitation were unsuccessful.

In analyzing this case study, consider the following questions:

Patient H, a White woman 60 years of age, suddenly began complaining of chest pain one evening. The pain was substernal, spread down both arms bilaterally, and radiated to her neck and jaw region. Patient H also complained of shortness of breath, nausea, and diaphoresis. Never having witnessed these symptoms before, Patient H's husband and daughter transported her to the local emergency department.

When she arrived in the emergency department, immediate priorities focused on obtaining a brief yet comprehensive history of symptomatology and past medical problems, as well as instituting appropriate treatments. The health assessment revealed numerous cardiovascular risk factors. Patient H's increasing age is one nonalterable risk factor present. In addition, she has a significant family history of CHD. Her mother and grandmother both suffered fatal heart attacks in their late 50s or early 60s. While Patient H does not have a history of smoking, she does have hypertension, hyperlipidemia, and diabetes. She is also obese, with a height of 5'2" and weight of 240 pounds and does not report engaging in a regular exercise program.

In terms of supportive treatment, Patient H was placed on 3 L of supplemental oxygen per nasal cannula and given sublingual nitroglycerin. She rated her pain an 8 on a 0 to 10 scale and did not report an appreciable decrease in her pain level after the first nitroglycerin dose. A second sublingual dose was given, after which she obtained relief. In the diagnostic workup phase, Patient H had a 12-lead ECG that revealed signs of ischemia in leads II and III and a ventricular dysrhythmia. Serial cardiac enzymes were drawn to rule out MI. Patient H was admitted to the coronary care unit (CCU) for treatment of an inferior MI.

Once transferred to the CCU, the patient was placed on the bedside monitor and a left radial arterial line and left subclavian Swan Ganz catheter were inserted for hemodynamic monitoring purposes. A bedside echocardiogram was performed to assess left ventricular EF and overall function of the chambers of the heart. The exam revealed that left ventricular EF was not preserved, estimated at only about 40% pumping function. Positive inotropes were started to increase the contractility of the heart and improve cardiac output. Intravenous nitroglycerin that was started in the emergency department was continued to improve coronary perfusion and for afterload reduction. After two days, Patient H was transferred out of the CCU to the cardiology stepdown unit. Telemetry showed slight sinus bradycardia at a rate of 56 beats per minute without ectopy. Other vital signs included blood pressure 102/56 mm Hg and a respiratory rate of 26 breaths per minute. Patient H remained on supplemental oxygen at 2 L per nasal cannula.

Cardiac rehabilitation was initiated when Patient H was in the stepdown unit. Rehabilitation activities first focused on identifying her risk stratification level, from low to high on a continuum, to guide initial activity and further exercise prescriptions. Because the patient's left ventricular EF was approximately 40%, her risk stratification level was identified as moderate and she was instructed that her cardiac rehabilitation activity would entail ambulating three times a day, first with monitored assistance in the hallway, working eventually toward the goal of independent ambulation. Prior to her first ambulation, Patient H's nurse took orthostatic blood pressure readings with the following results: lying 120/68 mm Hg; sitting 116/64 mm Hg; and standing 112/62 mm Hg. Heart rate pre-exercise was 58 beats per minute. As a result of these data, Patient H was assisted into the hallway for monitored ambulation. After walking for approximately two minutes, her heart rhythm converted from sinus bradycardia into a fast atrial fibrillation, with a ventricular rate of 180 beats per minute. Her blood pressure was 102/56 mm Hg. The patient was assisted back to bed, and a cardiology consult was requested.

The consulting cardiologist ordered a diltiazem drip. After her ventricular rate was under control, the patient was digitalized with 1 mg of digoxin followed by a maintenance dose of 0.125 mg IV. Other cardiac medications added to the regime included a beta blocker, furosemide, and potassium.

On the day of discharge, Patient H's family was present for discharge teaching. Her nurse explained the list of medications, including the dose and frequency, as well as her activity limitations. Patient H was instructed not to drive a car for two weeks and to increase her walking each day by one minute until she arrived at the goal of approximately 30 to 45 minutes at least three times a week. In addition, Patient H was informed about the nearest outpatient cardiac rehabilitation program. It was explained to her that the primary benefits of attending an outpatient program would be that the staff would assist her in developing an activity and exercise program individualized to her needs and physical capabilities. In addition, they would teach her and her family other components of heart healthy living, such as cardiac nutrition, managing diabetes, and stress.

After discharge, the patient did enroll in an outpatient cardiac rehabilitation program and had attended three sessions when she began developing symptoms of heart failure, including orthopnea, shortness of breath, and weight gain. On physical examination, crackles were auscultated bibasilarly and dependent pitting edema was present in her ankles bilaterally. On being seen in the heart failure clinic, she was restarted on a diuretic, furosemide, and an ACE inhibitor and her digoxin was kept at the same dosage.

In analyzing this case study, consider the following questions:

The following vignettes describe women with cardiac symptomatology who received either medical or surgical treatment. Read through these vignettes and analyze them using the questions that are presented at the end of the case studies.

In analyzing this case study, consider the following questions: