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Kornhauser Health Sciences Library

Shelby Watkins: Day 2

The Case

Day 2

Ms. Watkins is admitted to the Cardiac Intensive Care Unit a couple of hours after arrival in the ER. Her cardiac biomarkers are trended every 6 hours overnight, and her troponin peaks at 5.4. 

The next morning she is taken to the cardiac catheterization laboratory, where her angiogram shows the following results: 

    Left Anterior Descending Artery:  Mid 95% stenosis (image 2, yellow arrow)

    Left Circumflex Artery:  Proximal 70% stenosis (image 2, blue arrow)

    Right Coronary Artery:  Mid 70% stenosis (image 1, white arrow)

See Figures 4 and 5.

As there was no 100% occlusion of the artery, Ms. Watkins is returned to her room in the Cardiac Intensive Care Unit and her cardiologist discusses with her possible treatment options. The cardiologist explains that her options for 3-vessel coronary artery disease include:  Coronary Artery Bypass Grafting (CABG), Percutaneous Coronary Intervention (stenting), or medical management.  She explains that while CABG has been shown to give durability when compared to stenting (meaning decreased need for repeat opening of arteries in the future), most of the research studies did not include people of her age or with kidney disease.  CABG has serious considerations including need for open sternotomy, cardiopulmonary bypass and mechanical ventilation, and recovery time.  PCI will require her to take dual anti-platelet therapy for at least one year.  Given her age, comorbidities (particularly her chronic kidney disease), and likely long rehab time after CABG, the cardiologist recommends stenting. 

Ms. Watkins tells her cardiologist “just do whatever you think is best, honey.”  Her nurse is present for the discussion and expresses her concern to the cardiologist that because of her dementia, Mrs. Watkins might not be fully decisional, and that she has a living will on file that identifies her daughter Janet as her medical decision-maker.  The cardiologist then calls a family meeting over the phone with both adult daughters, who are making arrangements to travel to be with their mother in the next day or so and make plans about her living situation.  Her daughters are very concerned about putting their 90 year old mother through an open heart surgery, and opt for stenting.

Follow-up:

Ms. Watkins undergoes successful PCI of her LAD stenosis, with great improvement in her symptoms.  It is decided not to stent her other two lesions at this time, but to determine if they are causing her any symptoms.  After a 1-week stay in a rehab facility for physical therapy, Ms. Watkins returns to live with her daughter in Arizona, where she is set up with a cardiologist

appointment in a month.  She is symptom-free, without angina, able to do her activities of daily living without chest pain or shortness of breath.  She is taking her medications without any bleeding, and was taken off of the alendronate at hospital discharge based on her age and risk/benefit ratio of this medication.  She was also started on carvedilol and clopidogrel.

Three weeks after discharge, Ms. Watkins daughter takes her to her local ER with light-headedness and dizziness when going from sitting to standing.  It is discovered that she has orthostatic hypotension (Sitting BP 137/80 HR 70; Standing BP 105/70 HR 74), and upon reviewing her medications, the ER physician notes the long list of anti-HTN.  Two days later in the cardiologist office, the cardiologist stops her amlodipine and decreases her lisinopril dose.  Concerned about her ability to correctly manage the long list of medicines, the cardiologist asks Ms. Watkins who is responsible for the medications.  The patient responds that her daughter is putting pills into a pill box for her to take in the morning and evening.  The cardiologist explains the medication changes to her daughter, and schedules a visit with the RN in 2 weeks to re-check blood pressure.  With these changes, Ms. Watkins becomes symptom free.  BP at repeat check is 148/90, with no orthostatic changes.