BCH210H1 Lecture Notes - Nonsteroidal Anti-Inflammatory Drug, Oleic Acid, Amphiphile

31 views7 pages

scarletlouse599

31 Mar 2013

School

Department

Course

Professor

For unlimited access to Class Notes, a Class+ subscription is required.

hwpark22 and 40161 others unlocked

BCH210H1 Full Course Notes

Verified Note

49 documents

Document Summary

Risk factors contributing to cad: age group, total cholesterol level, hdl, bp after treatment; if no treatment- bp before treatment, smoker/non smoker. 17 risk points for men and 25 for women means that there is a 30% chance of coronary artery disease in. 10 years risk of cad> 20% (considering the above mentioned factors) or. It hydrolyzes tryglycerides breaks up ester linkages- making fatty acids and glycerol: this is done by lpl posted on a stalk on a capillary, as it identifies the protein tag on triacylglycerides. Ldl particles if prolonged in the circulatory system (as they are not being sucked up by receptor mediated endocytosis, it increases the chance of going into the artery wall. Important in blood coagulation as the cells stick together when they are activated (e. g. following a cut or vessel injury)- good thing in this case helps with glycoligation but harmful when there is no vessel damage or bleeding.

Related Questions

Medical History:
A 31 yr old man, a two pack per day smoker, presented to the emergency department complaining of sudden-onset, 10/10 crushing substernal chest pain associated with shortness of breath and diaphoresis that began 30 min prior to arrival. He had no previous history of cardiovascular disease.
Physical exam: Height 192 cm, weight 153.8 kg, BMI 41.6 kg Â· mâ2 (class III obesity); blood pressure 178/101 mmHg, pulse 75 beats Â· minâ1, respiratory rate 20 breaths Â· minâ1, temperature 36.7 âC; normal heart sounds, lungs clear to auscultation, normal peripheral pulses
Electrocardiogram: Normal sinus rhythm, rate 72 beats Â· minâ1; ST-segment elevation V1-V4
Chest radiograph: Normal Blood work: Elevated cTn and CK-MB; glucose normal; blood lipids: total cholesterol 200 mg Â· dlâ1, HDL-C 45 mg Â· dlâ1, LDL-C 134 mg Â· dlâ1, triglycerides 104 mg Â· dlâ1
Chest CT: No evidence of aortic dissection Echocardiogram: Left ventricular ejection fraction 45%, hypokinesis of the anteroseptal wall, borderline left ventricular enlargement, normal diastolic function, normal cardiac valves

Diagnosis:
Acute anterior wall STEMI.

Treatment:
1. Emergent cardiac catheterization (began 46 min after initial presentation to the hospital): total occlusion of the proximal left anterior descending (LAD) coronary artery, mild diffuse narrowing of the circumflex and right coronary arteries. The LAD occlusion was treated with thrombectomy, percutaneous coronary angioplasty, and placement of a drug-eluding stent, with good result.
2. Medical treatment: Aspirin, heparin, intravenous nitroglycerin, clopidogrel, abciximab, atorvastatin, carvedilol, lisinopril, nicotine patch.
3. Nicotine dependence consultation.
4. Referral to outpatient cardiac rehabilitation. Complications: None Hospital dismissal: Occurred approximately 48 h after admission; appointments made to see primary physician and to begin outpatient cardiac rehabilitation program in 5 d; follow-up blood work, ECG, and cardiology appointment in 8 wk Dismissal medications: Carvedilol, aspirin, clopidogrel, lisinopril, nicotine patch, simvastatin

Outpatient Exercise Test Results (Performed 8 D after Hospital Dismissal)
8.0 min duration (treadmill), normal blood pressure and electrocardiographic responses, peak heart rate 164 beats Â· minâ1, V.O2peak = 3.04 L Â· minâ1 (20.8 ml â kgâ1 â minâ1; 47% of expected), no angina reported
Exercise Prescription:
Outpatient cardiac rehabilitation program: Began 5 d after hospital dismissal; initial evaluations included assessments of neuromuscular function (normal), depression (normal), and potential sleep apnea (abnormalBerlin questionnaire, abnormal overnight oximetry resulted in referral for a sleep consultation); meeting with registered dietitian.
Exercise prescription: Goals included weight loss, increased aerobic and muscular fitness; frequency of three supervised sessions per week in cardiac rehabilitation facility plus three or four independent sessions per week (total frequency of six or seven sessions each week); average intensity using target heart rate 130 to 140 beats Â· minâ1 (60-70% heart rate reserve), RPE 12 to 14; high-intensity intervals (to begin 2 wk after starting cardiac rehabilitation) using RPE 17, heart rate <160 beats Â· minâ1; duration initially set at 10 to 15 min (not including warm-up, cool-down, strength training), gradually increasing to 45 to 60 min per session; types of exercise to include outdoor or treadmill walking, elliptical trainer; resistance training (to begin 2 wk after starting cardiac rehabilitation) using free weights and weight machines, initially one set of 8 to 15 slow repetitions, exercises for the major muscle groups, two or three sessions per week; lifestyle or general physical activity including walking short distances during the day, yard work, physical activity at work (return to work as restaurant equipment installer 4 wk after myocardial infarction).

Outcomes from 11 WK of Cardiac Rehabilitation Program
Medication compliance: Excellent (self-report) Exercise training: Frequency six or seven sessions per week (two or three supervised sessions per week); aerobic exercise duration 50 to 60 min per session; aerobic interval training two or three sessions per week (initially treadmill grade walking for 30 s progressing to slow jogging on treadmill for up to 4 min, three to five high-intensity intervals per session); resistance training two or three sessions per week, two or three sets of 8 to 15 repetitions, major muscle groups. Body weight: Stopped eating fast food and desserts, had more fruit, vegetables, poultry, fish; weight loss = 20.8 kg (BMI still excessive, 33.8 kg Â· mâ2). Repeat cardiopulmonary exercise test: 10.5 min duration (treadmill), normal blood pressure and electrocardiographic responses, peak heart rate 162 beats Â· minâ1, V.O2peak = 4.16 L Â· minâ1 (31.2 ml â kgâ1 â minâ1; 71% of expected), 37% increase in V.O2peak (L Â· minâ1), no angina reported. Tobacco use: One or two cigarettes daily. Blood pressure: 126/80 mmHg. Blood lipids: Total cholesterol 126 mg Â· dlâ1, HDL-C 33 mg Â· dlâ1, LDL-C 80 mg Â· dlâ1, triglycerides 65 mg Â· dlâ1. Recommendations: Stop smoking; continue medications, exercise program, and heart-healthy eating habits; continue efforts for weight loss; return appointment with cardiac rehabilitation team in 3 mo.

Discussion:
This patient was extremely young and was fortunate to realize the importance of promptly seeking medical attention with the onset of symptoms. His hospital course included standard diagnostic testing for acute myocardial infarction with subsequent timely coronary angiography with PCI of the infarct-related artery. Fortunately he did not develop serious complications and was discharged from the hospital after only 2 d. He enrolled in outpatient cardiac rehabilitation 1 wk after his MI. Of concern, he was markedly obese and may have had obstructive sleep apnea based on his abnormal Berlin questionnaire; he was referred for further evaluation in the Sleep Clinic. His course during rehabilitation was very favorable, and he did not experience post-infarction angina. He was successful in exercise and weight loss and demonstrated a remarkable increase in aerobic capacity. His challenge will be to continue taking his medications, stop smoking completely, eat a healthy diet, maintain his exercise program, and control his other coronary risk factors.

Questions:
1. What were this patientâs coronary risk factors?

2. What clinical tests were used to make the diagnosis of an acute ST-segment elevation anterior wall myocardial infarction?

3. What classes of cardiovascular medications were prescribed for this patient?

4. Compare the two cardiopulmonary exercise tests for this patient. What were the similarities? What were the differences?

5. Review the patientâs exercise prescription and program. Were the established goals achieved? Would you alter the exercise program in any fashion?

6. How effective was the patient in controlling his coronary risk factors by the time he completed 11 wk in the outpatient cardiac rehabilitation program?

7. What is his most important remaining coronary risk factor?

8. What component of the recommendations given to him at the completion of 11 wk of cardiac rehabilitation will potentially help him in sustaining his efforts at secondary prevention?

Case Study:

Initial history

40-year-old male complaining of substernal chest pain that began approximately 30 minutes

Before he came to the emergency department

Pain has eased slightly but is still present, was 8/10 in severity, now 5/10

Additional history

Also feels pain in his left shoulder

Feels short of breath and somewhat sick to his stomach, but has not vomited

Denies coughing, fever, or change in the nature of the pain with deep breathing

40pack/year history of smoking

Blood pressure has been a little elevated (148/92mmHg) on his last two vistis to his nurse practitioner

Eats a lot of fatty foods but says his total cholesterol doesnât change no matter what he eats; it was 242mg/dL last month

Father has angina that began at age 53

Denies diabetes

Exercises regularly and has not gained weight

Says he has had a couple of episodes of shortness of breath while jogging but attributed it to âgrowing oldâ

Has never been hospitalized except for one case of influenza complicated by pneumonia 3 years ago

Perceives himself as very healthy, is on no medications, and has no known allergies

Physical Examination

Alert, moderately anxious man in mild distress.

T=37 orally, P=100 with occasional premature beat, RR=24, BP=160/98 in both arms (sitting).

Skin warim and disphoretic without cyanosis

PERRLA, fundi benign, pharynx clear

Neck supple withour thyromegaly, adenopathy, or bruits

<2cm jugular venous distention

Tachypneic, mild use of accessory muscle of respoiration

No tenderness upon palpation of the chest wall

No dullness to precussion

Slight inspiratory crachles (rales) heard at both bases without egophony

No Rubs

Abdomen with bowel sounds heard throughout, no organomegaly or tenderness, no bruits, rectal guaiac negative

Extremities with full and symmetric pulses; slight bruit over left femoral artery, no pedal edema

Alter and oriented, neurologic examination intact to cognition, strength, sensation, gait, and deep tendon reflexes.

Diagnostic results

ECG shows 4mm ST elevation with T-wave inversion in the anterior precordial leads with occasional premature ventricular contraction

Oximetry shows oxygen saturation of 95%

Chest radiograph with borderline cardiomegaly and mild pulmonary congestion without acute infiltrates or pleural disease and no widening of the mediastinum.

Electrolytes and CBC normal

PT and PTT normal

CPK-MB normal

Troponin I normal

Please explain the pathophysiology and related treatment for this case study?

Medical History and Physycal E x a m i n a t i o n:
At age 7, Mr. AT suffered a series of seizures, and after a physical e x a m, lab tests, and electroencephalography, he was diagnosed with epilepsy and put on epileptic medication. He has gained 25 lb (11 kg) over the last 2 yr. He complains about excessive postural sway and loss of balance while walking and therefore uses his fatherâs cane. He has no history of smoking or alcohol consumption, but he has a familial history of diabetes. At a recent physical e x a m his low-density lipoprotein cholesterol (LDL-C) was 178 mg Â· dlâ1, high-density lipoprotein (HDL) was 61 mg Â· dlâ1, fasting glucose was 88 mg Â· dlâ1, and waist circumference was 42 in. (107 cm). He is currently on Carbatrol (carbamazepine) and baclofen.

Diagnosis:
Mr. AT, now 28 yr old, was born prematurely along with his twin sister at 34 wk. His mother experienced a severe infection early in her pregnancy and was hospitalized for several days; upon birth he had an Apgar score of 4. At age 1 he was diagnosed with spastic hemiplegia.

Exercise Test Results:
Because Mr. AT is ambulatory but has balance difficulties, leg cycle ergometry was chosen as the method of aerobic exercise testing. His resting blood pressure and heart rate in a seated position were 134/80 mmHg and 82 beats Â· minâ1, respectively. A small face mask was used to provide an adequate seal. A toe clip on his right side was used to maintain proper foot positioning on the pedals, and an adaptive glove was used to help his right hand grip the handlebar throughout the test. Mr. AT performed a 2 min warm-up without resistance. The leg cycle ergometry test began at 25 W at a cadence of 50 to 60 rpm. The protocol consisted of 2 min stages with an increase of 15 W per stage. The following data were collected during the exercise test.
The exercise test was terminated at 5:15 because of increased hip adductor spasticity and inability to maintain speed of 50 rpm, and by request of the participant because of shortness of breath. No signs of electrocardiogram abnormalities were present during the test. His V.O2 at 5:00 was 16 ml Â· kgâ1 Â· minâ1. The RER was <1.00 and the heart rate and V.O2 failed to reach peak. This was not a valid peak V.O2 test.
Because of the termination of the clinical leg cycle ergometry test, a more functional approach was chosen. The Timed Get Up and Go test was used as a baseline measure. This test used the following protocol.
Test Instructions
1. Starting position: Sit upright against the chair.
2. Stand up from the chair (time start).
3. Move quickly along the line toward the opposite end.
4. Touch the end and pivot back toward the chair.
5. Move quickly all the way back to the chair.
6. Pivot.
7. Sit back down (time end).
The total distance was 10 ft (3.05 m). The test was performed three times. Mr. ATâs scores were 42 s, 38 s, and 40 s. (A score over 30 s suggests a higher risk of falls.) Mr. AT used his assistive device during all testing.

Exercise Prescription:
Using the information presented in the medical history and exercise testing sections and in tables 27.9 through 27.11, develop an exercise prescription that encompasses aerobic, strength, flexibility, and neuromuscular training. Consider the different modes for each of the exercise training domains and the frequency, duration, intensity, and progression of each.

Questions:
1. How would the clinical exercise physiologist best determine the appropriate resistance levels to prescribe for this person?

2. What factors represented in the ICF model should the clinical exercise physiologist take into consideration to increase the adherence level and success of this client?

3. What fall prevention strategies should be incorporated into the exercise prescription for an individual who is at increased risk for falls?

4. Is the assistive device described in this case study appropriate for use by Mr. AT?

5. How should the clinical exercise physiologist incorporate weight loss strategies into the goals for this client?

BCH210H1 Lecture Notes - Nonsteroidal Anti-Inflammatory Drug, Oleic Acid, Amphiphile

BCH210H1 Full Course Notes

Document Summary

Get access

Related textbook solutions

Chemistry: Structure and Properties

Basic Chemistry

Principles of Chemistry Molecular Approach

Chemistry: Structure and Properties

Principles of Chemistry Molecular Approach

Chemistry: A Molecular Approach

Chemistry: A Molecular Approach

Principles of Chemistry: A Molecular Approach

Chemistry: The Central Science

Related Documents

BCH210H1 Study Guide - Carotid Artery Stenosis, Low-Density Lipoprotein, Transient Ischemic Attack

NURS 3664 Lecture Notes - Lecture 7: Coronary Artery Disease, Coronary Circulation, Collateral Circulation

BIMS 201 Lecture Notes - Lecture 10: Abdominal Obesity, High-Level Data Link Control, Proteinuria

Related Questions