low-risk cardiac patient case study andrew gerhard, h.bsc(kin),c.k. cardiac rehabilitation centre...
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Low-risk Cardiac PatientCase Study
Andrew Gerhard, H.BSc(Kin),C.K.
Cardiac Rehabilitation Centre
Hôpital régional de Sudbury Regional Hospital
Basic Demographics
• Mr. Homer Simpson• 41 year old male• Married, 3 children• Employed at power
plant• Leisure activities
include bowling, watching TV
Medical History
• 5-year history of angina on exertion
• Angina unstable over last 2½ years
• ‘Positive’ stress test result
• Angiogram: severe triple vessel disease
• Grade 1 ventricle, 65% ejection fraction
• CABG X5 three weeks ago
Coronary Risk FactorsModifiable
DYSLIPIDEMIA
• On Pravachol with good control• Total Chol: 3.63 mmol/l• LDL Chol: 1.99 mmol/l• HDL Chol: 1.29 mmol/l• TC/HDL: 2.81• Triglycerides: 0.78 mmol/l
Coronary Risk FactorsModifiable
Overweight
• Ht: 5’9”
• Wt: 255 lb.
• BMI: 39
• Waist/hip ratio: 1.4
Coronary Risk FactorsModifiable
PSYCHOLOGICAL ISSUES / STRESS
• no drug plan
• financial stress
• employer notco-operative inproviding modifiedreturn to work
Coronary Risk FactorsNonmodifiable
FAMILY HISTORY
• Homer’s brother diedat age 51 from a MI
Clinical Examination
• Pulse: 80/min and regular• Bp: 128/80• Chest and left leg incisions clean, dry
and intact• A / E clear bilaterally• Mild edema to left ankle
bilateral B/K TED stockings
Medications
• Pravachol - 40 mg OD
• Metoprolol - 50 mg BID
• EC ASA - 325 mg OD
Functional Capacity
• Routine stress test post CABG
• Completed Stage IV Bruce Protocol
• 12.5 METS (4.2 mph, 16% grade)
• Non-ischemic
Risk Stratification
• Risk of Disease Progression: 2.6
• Risk of Acute Event: 0
• Total score: 2.6
Risk Factor ManagementObesity and Dyslipidemia
Diet:
• Follow Canada’s Food Guide or AHA Step 1 diet
• Set reasonable weight goal
• Emphasize positiveresults from smallweight loss
Risk Factor ManagementObesity and Dyslipidemia
Exercise:
• Expect compliance issues
• Provide frequent initial support
• Set specific goals / rewards
• Encourage socialsupport
Risk Factor ManagementObesity and Dyslipidemia
Exercise: FITT principle
F - 3 to 5 times a week
I - HR 30 beats above resting
T - From 15 minutes a day initial to 40 minutes per day after 3 months
T - Walking or cycling
Risk Factor ManagementStress Management
Medication Expenses
• Explore less costly medication substitutions
• Ask physician for sample medications
• Explore “Trillium Foundation”
Risk Factor ManagementStress Management
Vocational Issues
• Can safely sustain work < 50% of max MET level (< than 6 METS)
• Corresponds to medium worklevel (up to 50lb handledon occasional basis)
• Need to have PDA of job
Risk Factor ManagementStress Management
Vocational Issues
• Fear plays biggest factor
• Employer not required to modify job
• Get help from OH&S department, LTD provider