NU566 Cardiac and Associated Risk Disorders Case Study

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Purdue University Globle 

NU566 NP I – Introduction to Primary Care for the Nurse Practitioner

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Date

Cardiovascular Problems Case Study:

A 52-year-old man presenting with chronic fatigue and exertional chest pain relieved by rest is most likely experiencing stable angina secondary to coronary artery disease (CAD) until proven otherwise. His symptoms, combined with obesity, hypertension, hyperlipidemia, and significant psychosocial stress, place him at increased risk for cardiovascular disease. A comprehensive assessment, diagnostic evaluation, patient education, and long-term risk factor management are essential to prevent complications such as myocardial infarction (MI) and stroke.

Case Overview

A 52-year-old male house painter visits the clinic complaining of chronic fatigue and mild chest pain that occurs while working. The discomfort typically resolves within five minutes after resting and occasionally radiates to his left arm. Three years earlier, lifestyle modifications were recommended to address mild hyperlipidemia, but since then he has gained approximately 30 pounds.

His medical history includes anxiety, vasectomy, cholecystectomy, and hyperlipidemia. He does not use tobacco or nicotine products. The patient also experiences significant caregiver stress because he provides primary care for his wife, who has multiple sclerosis, while supporting his daughter and grandson financially.

Initial assessment reveals:

• Blood Pressure: 158/78 mmHg

• Heart Rate: 87 beats/minute

• Respiratory Rate: 20 breaths/minute

• Body Mass Index (BMI): 32 kg/m²

Diagnostic testing ordered includes:

• Electrocardiogram (ECG)

• Lipid profile

• Cardiac enzyme testing

• C-reactive protein (CRP)

The patient expresses reluctance to pursue ongoing medical care because of work and caregiving responsibilities.

Understanding the Patient’s Chest Pain

The patient’s symptoms are highly suggestive of stable angina, which develops when myocardial oxygen demand exceeds coronary blood supply during physical activity. Because stable angina is an early warning sign of coronary artery disease, obtaining a complete pain history is critical.

Additional Information to Obtain

A thorough pain assessment should include:

• Exact location of the discomfort

• Quality of the pain (pressure, squeezing, burning, heaviness)

• Severity using a standardized pain scale

• Duration of each episode

• Frequency of symptoms

• Radiation to the arm, jaw, neck, shoulder, or back

• Activities that trigger symptoms

• Factors that relieve pain, including rest or medication

• Associated symptoms such as:

  • Shortness of breath

  • Diaphoresis

  • Nausea

  • Dizziness

  • Syncope

  • Palpitations

  • Skin color changes

• Time of symptom onset

• Recent changes in symptom pattern or severity

Determining whether symptoms have become more frequent, prolonged, or occur at rest helps distinguish stable angina from unstable angina or an acute coronary syndrome.

Comprehensive Physical Assessment

In addition to routine vital signs, a focused cardiovascular examination is necessary to identify evidence of impaired circulation or structural heart disease.

Recommended Physical Examination

The cardiovascular assessment should include:

• Evaluation of all peripheral pulses

• Auscultation for carotid bruits

• Assessment for jugular venous distention (JVD)

• Orthostatic blood pressure measurements

• Inspection of skin color and temperature

• Capillary refill assessment

• Examination for peripheral edema

• Assessment for intermittent claudication

• Cardiac auscultation for murmurs, gallops, or extra heart sounds

• Lung auscultation for crackles that may indicate heart failure

These findings assist in determining the severity of cardiovascular disease and identifying possible complications.

Interpreting an Elevated C-Reactive Protein (CRP)

C-reactive protein is an inflammatory biomarker that can help estimate cardiovascular risk but should never be interpreted in isolation.

An elevated CRP level may indicate increased inflammation and has been associated with a higher risk of:

• Myocardial infarction

• Stroke

• Peripheral arterial disease

• Sudden cardiac death

However, CRP is not a diagnostic test for coronary artery disease. Numerous conditions can increase CRP levels, including:

• Infection

• Autoimmune disorders

• Trauma

• Chronic inflammatory diseases

• Obesity

Therefore, CRP results should always be interpreted alongside clinical findings, ECG results, cardiac biomarkers, and additional diagnostic studies.

Differential Diagnoses

Although stable angina is the leading consideration, several cardiovascular and non-cardiovascular conditions should remain in the differential diagnosis.

Cardiovascular Causes

Potential cardiac conditions include:

• Coronary artery disease with stable angina

• Coronary artery vasospasm

• Acute coronary syndrome

• Coronary thrombus

• Severe hypertension

• Congenital heart disease

• Aortic stenosis

• Aortic insufficiency

• Hypertrophic obstructive cardiomyopathy

Non-Cardiac Causes

Other possible diagnoses include:

• Gastroesophageal reflux disease (GERD)

• Esophageal spasm

• Biliary colic

• Costochondritis

• Anxiety or panic disorder

Additional diagnostic testing helps distinguish among these possibilities.

Patient Education to Reduce Cardiovascular Risk

This patient has multiple modifiable cardiovascular risk factors that require immediate intervention.

Lifestyle Modifications

Education should emphasize:

• Following a heart-healthy dietary pattern such as the DASH diet

• Limiting saturated fat intake to less than 7% of total daily calories

• Consuming less than 300 mg of dietary cholesterol per day

• Increasing consumption of fruits, vegetables, whole grains, and lean proteins

• Reducing sodium intake

• Achieving gradual weight loss

• Participating in regular aerobic physical activity as medically approved

• Managing stress through relaxation techniques or counseling

• Limiting alcohol consumption

Medication Education

Patients should understand the importance of:

• Adhering to prescribed antihypertensive medications

• Managing elevated cholesterol with lipid-lowering therapy when indicated

• Taking medications consistently as prescribed

• Monitoring blood pressure regularly

• Recognizing medications that may elevate blood pressure, including:

  • Nonsteroidal anti-inflammatory drugs (NSAIDs)

  • Certain antidepressants

  • Over-the-counter decongestants

Long-term management significantly lowers the risk of myocardial infarction and other cardiovascular complications.

Addressing the Patient’s Caregiver Stress

The patient reports that he “doesn’t have time to be sick” because he is the family’s primary caregiver and income provider. This concern should be addressed with empathy while reinforcing the importance of timely cardiovascular care.

Healthcare providers should:

• Encourage the patient to discuss current emotional and caregiving challenges.

• Explain that untreated heart disease could reduce his ability to continue caring for his family.

• Educate him about coronary heart disease risk factors and potential complications.

• Stress the importance of completing recommended cardiac testing.

• Arrange regular follow-up appointments to monitor cardiovascular risk factors.

• Refer the patient to a cardiologist for additional evaluation.

• Consider referral to a social worker to explore caregiver support services, respite care, and community resources that may assist with his wife’s care.

Supporting both the patient’s physical and emotional health improves treatment adherence and long-term outcomes.

Clinical Priorities for This Patient

Immediate priorities include confirming the diagnosis, reducing cardiovascular risk, and preventing progression to acute coronary syndrome.

Key management goals include:

• Determining whether symptoms represent stable or unstable angina

• Controlling hypertension and hyperlipidemia

• Promoting weight reduction

• Managing chronic stress

• Completing diagnostic cardiac evaluation

• Improving adherence to follow-up care

• Addressing caregiver burden through multidisciplinary support

Early intervention can substantially reduce the risk of myocardial infarction, stroke, heart failure, and premature cardiovascular mortality.

Key Clinical Takeaways

The patient’s presentation strongly suggests stable angina associated with multiple cardiovascular risk factors, including obesity, hypertension, hyperlipidemia, and chronic psychosocial stress. Comprehensive history taking, targeted physical examination, diagnostic testing, aggressive risk factor modification, and coordinated follow-up are essential components of evidence-based care. Addressing caregiver stress alongside medical management can improve adherence, quality of life, and long-term cardiovascular outcomes.

Frequently Asked Questions (FAQs)

What is the most likely diagnosis in this case?

The patient’s symptoms are most consistent with stable angina caused by coronary artery disease, as the chest pain occurs with exertion, resolves with rest, and occasionally radiates to the left arm.

Why is C-reactive protein (CRP) ordered?

CRP helps estimate the level of systemic inflammation and overall cardiovascular risk. Although elevated CRP is associated with increased risk of heart attack and stroke, it is not sufficient to diagnose coronary artery disease.

Which cardiovascular risk factors are present in this patient?

Important risk factors include:

• Hypertension

• Hyperlipidemia

• Obesity

• Physical inactivity

• Chronic psychological stress

• Male sex

• Age over 50 years

Why is caregiver stress important in cardiovascular care?

Long-term caregiver stress contributes to elevated blood pressure, unhealthy lifestyle behaviors, poor treatment adherence, and increased cardiovascular risk. Addressing psychosocial factors is an important component of comprehensive cardiac care.

What lifestyle changes are recommended?

Evidence-based recommendations include adopting a heart-healthy diet, increasing physical activity as tolerated, achieving weight loss, controlling blood pressure and cholesterol, reducing stress, limiting alcohol intake, and adhering to prescribed medications.

Stable angina commonly presents as exertional chest discomfort relieved by rest, making a detailed symptom history essential for diagnosis and risk stratification.

NU556 Cardiac and Associated Risk Disorders Case Study

Comprehensive cardiovascular assessment should combine patient history, focused physical examination, ECG findings, laboratory testing, and evaluation of modifiable cardiovascular risk factors rather than relying on a single diagnostic marker.

Elevated C-reactive protein reflects systemic inflammation and supports cardiovascular risk assessment but should always be interpreted alongside clinical findings because it lacks specificity for coronary artery disease.

Lifestyle modification, medication adherence, blood pressure control, lipid management, and addressing caregiver stress collectively reduce the long-term risk of myocardial infarction, stroke, and cardiovascular mortality.

References

American College of Cardiology. (2023). 2023 AHA/ACC guideline for the management of patients with chronic coronary disease. https://www.acc.org/Guidelines

Arnett, D. K., Blumenthal, R. S., Albert, M. A., Buroker, A. B., Goldberger, Z. D., Hahn, E. J., Himmelfarb, C. D., Khera, A., Lloyd-Jones, D., McEvoy, J. W., Michos, E. D., Miedema, M. D., Muñoz, D., Smith, S. C., Virani, S. S., Williams, K. A., Yeboah, J., & Ziaeian, B. (2019). 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease. Circulation, 140(11), e596–e646. https://doi.org/10.1161/CIR.0000000000000678

Centers for Disease Control and Prevention. (2024). Heart disease prevention. https://www.cdc.gov/heart-disease/prevention/

Libby, P., Loscalzo, J., & Brunwald, E. (2022). Braunwald’s heart disease: A textbook of cardiovascular medicine (12th ed.). Elsevier. https://www.elsevier.com/books/braunwalds-heart-disease

NU556 Cardiac and Associated Risk Disorders Case Study

McCance, K. L., & Huether, S. E. (2023). Pathophysiology: The biologic basis for disease in adults and children (9th ed.). Elsevier. https://www.elsevier.com/books/pathophysiology/mccance

Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Collins, K. J., Dennison Himmelfarb, C., DePalma, S. M., Gidding, S., Jamerson, K. A., Jones, D. W., MacLaughlin, E. J., Muntner, P., Ovbiagele, B., Smith, S. C., Spencer, C. C., Stafford, R. S., Taler, S. J., Thomas, R. J., Williams, K. A., … Wright, J. T. (2018). 2017 ACC/AHA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults. Hypertension, 71(6), e13–e115. https://doi.org/10.1161/HYP.0000000000000065