CARDIOVASCULAR

DISEASE

BIOLOGY PROJECT

DONE BY:
SATCHI KOWSIGAN
GRADE 11-E

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 PARTICULARS

Name: Satchi Kowsigan

Class: 11-E
G.R. No: 7740
Topic: Cardiovascular Disease
Teacher in-Charge: Ms. Sofiya Nasar
Sign of Teacher:

Sign of Principal:

Sign of External Examiner:

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 Acknowledgement

I would like to express my greatest appreciation to

everyone who helped and supported me
throughout the project. I am thankful to my Biology
Teacher, Ms. Sofiya Nasar for her ongoing support
during the project.
Her advice and encouragement had a huge role to
finalize this project report.
I would also like to thank all of my classmates who
helped me in completing the project by exchanging
interesting ideas and sharing their experiences.
I wish to thank my parents as well for their support
and encouragement without which I could not have
completed this project in the limited timeframe.
In the end, I want to thank my friends who
displayed appreciation for my work and motivated
me to continue my work.

CONTENTS
S.n Content Page. No
o
1 What is cardiovascular 5
3
 disease?
2 Cause 6
2 Risk Factor 6
3 Types of CDV 7
4 Symptoms 8
5 Effects 12
6 Prevention 13
7 Diagnosis 17
8 Cure 19
9 Surgery and its risks 21
9 Role of Cardiac anesthesiologist 25
10 Case study 28
11 Bibliography 33

What is cardiovascular disease?

The cardiovascular system consists of the heart and blood vessels. There is a wide
array of problems that may arise within the cardiovascular system. Although CVD

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may directly arise from different etiologies such as emboli in a patient with atrial
fibrillation resulting in ischemic stroke, rheumatic fever causing valvular heart
disease, among others, addressing risks factors associated to the development of
atherosclerosis is most important because it is a common denominator in the
pathophysiology of CVD. Cardiovascular diseases (CVD) remain among the 2
leading causes of death in the United States since 1975 with 633,842 deaths or 1
in every 4 deaths, heart disease occupied the leading cause of death in 2015
followed by 595,930 deaths related to cancer. CVD is also the number 1 cause of
death globally with an estimated 17.7 million deaths in 2015, according to the
World Health Organization (WHO). The burden of CVD further extends as it is
considered the most costly disease even ahead of Alzheimer disease and diabetes
with calculated indirect costs of $237 billion dollars per year and a projected
increased to $368 billion by 2035.

The Cause of CVD

Damage to the circulatory system can also result from diabetes and
other health conditions, such as a virus, an inflammatory process such
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 as myocarditis, or a structural problem present from birth (congenital
heart disease).

CVD often results from high blood pressure, which produces no

symptoms. It is therefore vital that people undergo regular screening
for high blood pressure.

The Risk factor of CVD

A risk factor is something that increases the chance of getting a
condition. The more you have, the higher your chance of CVD. Even if
you can’t change all your risk factors, there are steps you can take
to reduce your risk.

There are several risk factors for CVD, including:

 smoking

 stress

 alcohol

 high blood pressure

 high blood cholesterol

 being physically inactive

 being overweight or obese

 diabetes

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 family history of heart disease

 ethnic background

 sex - men are more likely to get CVD earlier than women

 Age - the older you are, the more likely you are to get CVD.

Types of CVD

Coronary heart disease – a disease of the blood vessels supplying the

heart muscle;

Cerebrovascular disease – a disease of the blood vessels supplying the

brain;

Peripheral arterial disease – a disease of blood vessels supplying the

arms and legs;

Rheumatic heart disease – damage to the heart muscle and heart

valves from rheumatic fever, caused by streptococcal bacteria;

Congenital heart disease – birth defects that affect the normal

development and functioning of the heart caused by malformations of
the heart structure from birth; and

Deep vein thrombosis and pulmonary embolism – blood clots in the leg
veins, which can dislodge and move to the heart and lungs.

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Heart attacks and strokes are usually acute events and are mainly
caused by a blockage that prevents blood from flowing to the heart or
brain. The most common reason for this is a build-up of fatty deposits
on the inner walls of the blood vessels that supply the heart or brain.
Strokes can be caused by bleeding from a blood vessel in the brain or
from blood clots.

Symptoms
Symptoms of heart disease in the blood
vessels

Coronary artery disease is a common heart condition that affects the

major blood vessels that supply the heart muscle. Cholesterol deposits
(plaques) in the heart arteries are usually the cause of coronary artery
disease. The buildup of these plaques is called atherosclerosis (ath-ur-
o-skluh-ROE-sis). Atherosclerosis reduces blood flow to the heart and
other parts of the body. It can lead to a heart attack, chest pain (angina)
or stroke.

Coronary artery disease symptoms may be different for men and

women. For instance, men are more likely to have chest pain. Women
are more likely to have other symptoms along with chest discomfort,
such as shortness of breath, nausea and extreme fatigue.

Symptoms of coronary artery disease can include:

 Chest pain, chest tightness, chest pressure and chest discomfort

(angina)
 Shortness of breath
 Pain in the neck, jaw, throat, upper belly area or back

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  Pain, numbness, weakness or coldness in the legs or arms if the
blood vessels in those body areas are narrowed

Heart disease symptoms caused by irregular

heartbeats (heart arrhythmias)

The heart may beat too quickly, too slowly or irregularly. Heart
arrhythmia symptoms can include:

 Chest pain or discomfort

 Dizziness
 Fainting (syncope) or near fainting
 Fluttering in the chest
 Lightheadedness
 Racing heartbeat (tachycardia)
 Shortness of breath
 Slow heartbeat (bradycardia)

Heart disease symptoms caused by

congenital heart defects
Serious congenital heart defects usually are noticed soon after birth.
Congenital heart defect symptoms in children could include:

 Pale gray or blue skin or lips (cyanosis)

 Swelling in the legs, belly area or areas around the eyes

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  In an infant, shortness of breath during feedings, leading to poor
weight gain
Less-serious congenital heart defects are often not diagnosed until later
in childhood or during adulthood. Symptoms of congenital heart
defects that usually aren't immediately life-threatening include:

 Easily getting short of breath during exercise or activity

 Easily tiring during exercise or activity
 Swelling of the hands, ankles or feet

Heart disease symptoms caused by disease

heart muscle (cardiomyopathy)
Early stages of cardiomyopathy may not cause noticeable symptoms. As
the condition worsens, symptoms may include:

 Dizziness, lightheadedness and fainting

 Fatigue
 Feeling short of breath during activity or at rest
 Feeling short of breath at night when trying to sleep or waking up
short of breath
 Irregular heartbeats that feel rapid, pounding or fluttering
 Swollen legs, ankles or feet

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Heart disease symptoms caused by heart
valve problems (valvular heart disease)
The heart has four valves — the aortic, mitral, pulmonary and tricuspid
valves. They open and close to move blood through the heart. Many
things can damage the heart valves. A heart valve may become
narrowed (stenosis), leaky (regurgitation or insufficiency) or close
improperly (prolapse).

Valvular heart disease is also called heart valve disease. Depending on

which valve isn't working properly, heart valve disease symptoms
generally include:

 Chest pain
 Fainting (syncope)
 Fatigue
 Irregular heartbeat
 Shortness of breath
 Swollen feet or ankles

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Endocarditis is an infection that affects the heart valves and inner lining
of the heart chambers and heart valves (endocardium). Endocarditis
symptoms can include:

 Dry or persistent cough

 Fever
 Heartbeat changes
 Shortness of breath
 Skin rashes or unusual spots
 Swelling of the legs or belly area
 Weakness or fatigue

Effects of CVD

With less blood flow, your heart doesn’t get the oxygen it needs, and
that can cause chest pain, called angina, especially when you exercise
or do heavy labor. It also can affect how well your heart pumps and
make the rest of your body short on oxygen, too. Without it, your cells
won’t work as well as they should, and you may be short of breath or
feel more tired than usual. If plaque breaks off and totally blocks an
artery, you have a heart attack.

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 Prevention of CVD

Heart disease is a leading cause of death. You can't change some risk
factors for it, such as family history, sex at birth or age. But you can
take plenty of other steps to lower your risk of heart disease.
Get started with these eight tips to boost your heart health:

1. Don’t smoke or use tobacco

One of the best things you can do for your heart is to stop smoking or
using smokeless tobacco. Even if you're not a smoker, be sure to stay
away from secondhand smoke.
Chemicals in tobacco can damage the heart and blood vessels. Cigarette
smoke lowers the oxygen in the blood, which raises blood pressure and
heart rate. That's because the heart has to work harder to supply
enough oxygen to the body and brain.
There's good news though. The risk of heart disease starts to drop in as
little as a day after quitting. After a year without cigarettes, the risk of
heart disease drops to about half that of a smoker. No matter how long
or how much you smoked, you'll start reaping rewards as soon as you
quit.

2. Get moving: Aim for at least 30 to 60

minutes of activity daily
.Regular, daily physical activity can lower the risk of heart disease.
Physical activity helps control your weight. It also lowers the chances of

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getting other conditions that may put a strain on the heart. These
include high blood pressure, high cholesterol and type 2 diabetes.
If you haven't been active for a while, you may need to slowly work
your way up to these goals. But in general, you should aim for at least:

 150 minutes a week of moderate aerobic exercise, such as walking at

a brisk pace.
 75 minutes a week of vigorous aerobic activity, such as running.
 Two or more strength training sessions a week.
Even shorter bouts of activity offer heart benefits. So if you can't meet
those guidelines, don't give up. Just five minutes of moving can help.
Activities such as gardening, housekeeping, taking the stairs and
walking the dog all count toward your total. You don't have to exercise
hard to benefit. But you can see bigger benefits if you boost the
intensity, length and frequency of your workouts.

3. Eat a heart-healthy diet

A healthy diet can help protect the heart, improve blood pressure and
cholesterol, and lower the risk of type 2 diabetes. A heart-healthy
eating plan includes:

 Vegetables and fruits.

 Beans or other legumes.
 Lean meats and fish.
 Low-fat or fat-free dairy foods.
 Whole grains.
 Healthy fats such as olive oil and avocado.
Two examples of heart-healthy food plans include the Dietary
Approaches to Stop Hypertension (DASH) eating plan and the
Mediterranean diet.
Take in less of the following:

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 Salt or high-sodium meals.
 Sugar or sweetened beverages.
 Highly refined carbohydrates.
 Alcohol.
 Highly processed food, such as processed meats.
 Saturated fat, which is found in red meat, full-fat dairy products,
palm oil and coconut oil.
 Trans fat, which is found in some fried fast food, chips and baked
goods.

4. Maintain a healthy weight

Being overweight — especially around the middle of the body — raises
the risk of heart disease. Extra weight can lead to conditions that raise
the chances of getting heart disease. These conditions include high
blood pressure, high cholesterol and type 2 diabetes.
The body mass index (BMI) uses height and weight to find out whether
a person is overweight or obese. A BMI of 25 or higher is considered
overweight. In general, it's linked with higher cholesterol, higher blood
pressure, and an increased risk of heart disease and stroke.
Waist circumference also can be a useful tool to measure how much
belly fat you have. The risk of heart disease is higher if the waist
measurement is greater than:

 40 inches (101.6 centimeters, or cm) for men.

 35 inches (88.9 cm) for women.
Even a small weight loss can be good for you. Reducing weight by just
3% to 5% can help lower certain fats in the blood called triglycerides. It
can lower blood sugar, also called glucose. And it can cut the risk of
type 2 diabetes. Losing even more helps lower blood pressure and
blood cholesterol levels.

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5. Get quality sleep
People who don't get enough sleep have a higher risk of obesity, high
blood pressure, heart attack, diabetes and depression.
Most adults need at least seven hours of sleep each night. Children
usually need more. So make sure you get enough rest. Set a sleep
schedule and stick to it. To do that, go to bed and wake up at the same
times each day. Keep your bedroom dark and quiet too, so it's easier to
sleep.
Talk to a member of your health care team if you feel like you get
enough sleep but you're still tired throughout the day. Ask if you need
to be evaluated for obstructive sleep apnea. It's a condition that can
raise your risk of heart disease. Symptoms of obstructive sleep apnea
include loud snoring, stopping breathing for short times during sleep
and waking up gasping for air. Treatment for obstructive sleep apnea
may involve losing weight if you're overweight. It also might involve
using a device that keeps your airway open while you sleep. This is
called a continuous positive airway pressure (CPAP) device.

6. Manage stress

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Ongoing stress can play a role in higher blood pressure and other risk
factors for heart disease. Some people also cope with stress in
unhealthy ways. For example, they may overeat, drink or smoke. You
can boost your health by finding other ways to manage stress. Healthy
tactics include physical activity, relaxation exercises, mindfulness, yoga
and meditation.
If stress becomes overwhelming, get a health care checkup. Ongoing
stress may be linked with mental health conditions such as anxiety and
depression. These conditions also are tied to heart disease risk factors,
including higher blood pressure and less blow flow to the heart. If you
think you might have depression or anxiety, it's important to get
treatment.

7. Get regular health screening test

High blood pressure and high cholesterol can damage the heart and
blood vessels. But if you don't get checked for these conditions, you
likely won't know whether you have them. Regular screening tests can
tell you what your numbers are and whether you need to take action.
 Blood pressure. Regular blood pressure screenings usually start in
childhood. Starting at age 18, blood pressure should be measured at
least once every two years. This checks for high blood pressure as a
risk factor for heart disease and stroke.
If you're between 18 and 39 and have risk factors for high blood
pressure, you'll likely be screened once a year. People age 40 and
older also are given a blood pressure test yearly.

 Cholesterol levels. The National Heart, Lung, and Blood Institute

(NHLBI) recommends that cholesterol screenings start between the
ages of 9 and 11. Earlier testing may be recommended if you have
other risk factors, such as a family history of early-onset heart

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 disease. After the first cholesterol test, screenings should be
repeated every five years. Then the timing changes with age.
The NHLBI recommends that women ages 55 to 65 and men ages 45
to 65 get screened every 1 to 2 years. People over 65 should get
their cholesterol tested once a year.
 Type 2 diabetes screening. Diabetes involves ongoing high blood
sugar levels. It raises the chances of getting heart disease. Risk
factors for diabetes include being overweight and having a family
history of diabetes. If you have any of the risk factors, your health
care team may recommend early screening. If not, screening is
recommended starting at age 45. Then you get your blood sugar
levels tested again every three years.
If you have a condition such as high cholesterol, high blood pressure or
diabetes, talk with your health care team. Your doctor may prescribe
medicines and recommend lifestyle changes. Make sure to take your
medicines exactly as prescribed, and follow a healthy-lifestyle plan.

Diagnosis
Many different tests are used to diagnose heart disease. Besides blood
tests and a chest X-ray, tests to diagnose heart disease can include:

 Electrocardiogram (ECG or EKG). An ECG is a quick and painless

test that records the electrical signals in the heart. It can tell if the
heart is beating too fast or too slowly.
 Holter monitoring. A Holter monitor is a portable ECG device that's
worn for a day or more to record the heart's activity during daily
activities. This test can detect irregular heartbeats that aren't found
during a regular ECG exam.
 Echocardiogram. This noninvasive exam uses sound waves to
create detailed images of the heart in motion. It shows how blood
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 moves through the heart and heart valves. An echocardiogram can
help determine if a valve is narrowed or leaking.
 Exercise tests or stress tests. These tests often involve walking on a
treadmill or riding a stationary bike while the heart is monitored.
Exercise tests help reveal how the heart responds to physical
activity and whether heart disease symptoms occur during
exercise. If you can't exercise, you might be given medications.
 Cardiac catheterization. This test can show blockages in the heart
arteries. A long, thin flexible tube (catheter) is inserted in a blood
vessel, usually in the groin or wrist, and guided to the heart. Dye
flows through the catheter to arteries in the heart. The dye helps
the arteries show up more clearly on X-ray images taken during the
test.
 Heart (cardiac) CT scan. In a cardiac CT scan, you lie on a table
inside a doughnut-shaped machine. An X-ray tube inside the
machine rotates around your body and collects images of your
heart and chest.
 Heart (cardiac) magnetic resonance imaging (MRI) scan. A
cardiac MRI uses a magnetic field and computer-generated radio
waves to create detailed images of the heart.

Cure
Medicines

Some medicines can reduce or prevent chest pain and manage other
medical conditions that may contribute to your coronary heart disease.

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 ACE inhibitors and beta blockers help lower blood pressure and
decrease how hard your heart is working.
 Calcium channel blockers lower blood pressure by allowing blood
vessels to relax.
 Medicines to control blood sugar, such as empagliflozin,
canagliflozin, and liraglutide, can help lower your risk for
complications if you have coronary heart disease and diabetes.
 Metformin controls plaque buildup if you have diabetes.

 Nitrates, such as nitroglycerin, dilate your coronary arteries and

relieve or prevent chest pain from angina.
 Ranolazine treats coronary microvascular disease and the chest pain
it may cause.
 Statins or non-statin therapies control high blood cholesterol. You
may need statin therapy if you have a higher risk of coronary heart
disease or stroke or if you have diabetes and are between ages 40
and 75.
 Non-statin therapies may be used to reduce cholesterol when statins
do not lower cholesterol enough or cause side effects. Your
healthcare provider may also prescribe non-statin drugs, such as
ezetimibe, bile acid sequestrants, alirocumab, or evolocumab to
lower cholesterol or gemfibrozil or fenofibrate to reduce triglycerides.
They may also recommend omega-3 fatty acids as a supplement to
your healthy diet.

Procedure

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 You may need a procedure or heart surgery to treat more serious
coronary heart disease.

 Percutaneous coronary intervention (PCI) opens coronary arteries

that are narrowed or blocked by the buildup of plaque. A small mesh
tube called a stent is usually implanted after PCI to prevent the artery
from narrowing again.
 Coronary artery bypass grafting (CABG) improves blood flow to the
heart by using normal arteries from the chest wall and veins from the
legs to bypass the blocked arteries. Surgeons typically use CABG to
treat people who have severe coronary artery disease in multiple
coronary arteries.
 Trans myocardial laser revascularization or coronary
endarterectomy treats severe angina linked to coronary heart
disease when other treatments are too risky or did not work.

Surgery and its risk

Heart surgery

Heart-related problems do not always require surgery. Sometimes they

can be addressed with lifestyle changes, medications, or nonsurgical
procedures. For example, catheter ablation uses energy to make small
scars in your heart tissue to prevent abnormal electrical signals from
moving through your heart. Coronary angioplasty is a minimally
invasive procedure in which a stent is inserted into a narrowed or
blocked coronary artery to hold it open. Nonetheless, surgery is often
needed to address problems such as heart failure, plaque buildup that
partially or totally blocks blood flow in a coronary artery, faulty heart

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 valves, dilated or diseased major blood vessels (such as the aorta), and
abnormal heart rhythms.

What are some types of heart surgery?

There are many types of heart surgery. The National Heart, Lung, and
Blood Institute, which is part of the National Institutes of Health, lists
the following as among the most common coronary surgical
procedures.

 Coronary artery bypass grafting (CABG). In CABG — the most common

type of heart surgery — the surgeon takes a healthy artery or vein from
elsewhere in your body and connects it to supply blood past the
blocked coronary artery. The grafted artery or vein bypasses the
blocked portion of the coronary artery, creating a new path for blood to
flow to the heart muscle. Often, this is done for more than one
coronary artery during the same surgery. CABG is sometimes referred
to as heart bypass or coronary artery bypass surgery.
 Heart valve repair or replacement. Surgeons either repair the valve or
replace it with an artificial valve or with a biological valve made from
pig, cow, or human heart tissue. One repair option is to insert a
catheter through a large blood vessel, guide it to the heart, and inflate
and deflate a small balloon at the tip of the catheter to widen a narrow
valve.
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  Insertion of a pacemaker or an implantable cardioverter defibrillator
(ICD). Medicine is usually the first treatment option for arrhythmia, a
condition in which the heart beats too fast, too slow or with an
irregular rhythm. If medication does not work, a surgeon may implant a
pacemaker under the skin of the chest or abdomen, with wires that
connect it to the heart chambers. The device uses electrical pulses to
control the heart rhythm when a sensor detects that it is abnormal. An
ICD works similarly, but it sends an electric shock to restore a normal
rhythm when it detects a dangerous arrhythmia.

 Maze surgery. The surgeon creates a pattern of scar tissue within the
upper chambers of the heart to redirect electrical signals along a
controlled path to the lower heart chambers. The surgery blocks the
stray electrical signals that cause atrial fibrillation — the most common
type of serious arrhythmia.

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 Aneurysm repair. A weak section of the artery or heart wall is replaced
with a patch or graft to repair a balloon-like bulge in the artery or wall
of the heart muscle.
 Heart transplant. The diseased heart is removed and replaced with a
healthy heart from a deceased donor.
 Insertion of a ventricular assist device (VAD) or total artificial heart
(TAH). A VAD is a mechanical pump that supports heart function and
blood flow. A TAH replaces the two lower chambers of the heart.

What are the risks?

Most heart surgeries are major surgeries. Although often successful,

they do entail risks. The National Heart, Lung, and Blood Institute
identifies some of these risks as:

 Bleeding
 Infection
 Reactions to anesthesia
 Damage to tissues in the heart, kidneys, liver, and lungs
 Stroke
 Death, especially for someone who is already very sick before surgery

The risk is higher if you have other diseases or conditions, such as

diabetes, peripheral artery disease, or kidney or lung disease.

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 What is the recovery time?

Recovery time depends on the type of surgery you have, but for most
types of heart surgery you are likely to spend a day or more in the
hospital’s intensive care unit. Then you will be moved to another part
of the hospital for several days until you go home.

The National Heart, Lung, and Blood Institute notes that the length of
your recovery time at home will depend on the type of surgery you had,
your overall health before the surgery, and whether you experienced
any complications from surgery. For example, full recovery from a
traditional coronary artery bypass may take six to 12 weeks or more.

Role of Cardiac anesthesiologist

A specially trained anesthesiologist, called a cardiac, cardiothoracic, or
cardiovascular anesthesiologist, is involved in your care before, during,
and after surgery.

 For nonemergency surgery, a cardiac anesthesiologist typically will

meet with you before the operation to explain the anesthesia
procedures, risks, and side effects. To help reduce your risk during
surgery, the anesthesiologist will review your medical history and
diagnostic tests, ask about prior reactions to anesthesia, and advise you

25
 on which of your medications you should stop or continue taking in the
days leading up to the operation.
 The anesthesiologist’s role during cardiac surgery is extensive and goes
beyond administering general anesthesia. The anesthesiologist
intensively monitors the patient’s condition in various ways. This
includes using special catheters in major blood vessels in the neck and
chest.
 Monitoring often includes the use of an ultrasound probe to evaluate
the heart valves and muscle function. The anesthesiologist will use this
ultrasound technology (called transesophageal echocardiography, or
TEE) to guide the surgeon during the procedure and to evaluate the
success of the surgical repairs. TEE also can help determine the cause of
emergency conditions such as low blood pressure or breathing
difficulties.
 If your surgery requires the use of a heart-lung bypass machine, the
anesthesiologist will administer a drug called heparin to prevent blood
from clotting as it passes through the machine. The surgeon often will
stop the heart from beating in order to perform the surgery. Once the
surgeon has completed the operation, the anesthesiologist will provide
medications or recommend other assistance to restart your heart and
restore its role in supporting your blood circulation. This concept may
sound scary, but the use of the heart-lung bypass machine is well
established. As of 2013, it was estimated that more than 1 million
cardiac operations were performed each year worldwide with the use
of the device.
 After surgery, the anesthesiologist will monitor your recovery from the
anesthesia and help direct your pain management. Anesthesiologists
also provide care for patients in the intensive care unit following

26
cardiac surgery, although this is not usually the same anesthesiologist
who provided your care in the operating room.

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Case study I
Dr. David M. Dudzinski: A 32-year-old man was evaluated in the
emergency department of this hospital for the abrupt onset of
postprandial chest pain.

Several hours before presentation, the patient had eaten pizza in his
apartment. Less than 1 hour later, while he was at rest and watching
television, “crushing” pain, diaphoresis, dyspnea, and nausea
developed. He rated the pain at 7 on a scale of 0 to 10 (with 10
indicating the most severe pain), and he noted that the pain did not
radiate or worsen with respiration. He attempted to induce vomiting
and took calcium carbonate tablets, but his condition did not improve.
After 2 hours of constant pain, he presented to the emergency
department of this hospital.

The patient had no medical history and took no medications. His father
had had a myocardial infarction when he was 51 years of age. The
patient was allergic to penicillin (unknown reaction). He lived with his
girlfriend, who had recently had streptococcal pharyngitis. He had been
under a great deal of stress because of a new job as a sales manager, a
move to a new apartment, and the recent death of a family pet. He
consumed a six-pack of beer daily. He had used cocaine (most recently
3 months earlier) but did not report using other illicit substances.

On examination, the temperature was 36.3°C, the heart rate 83 beats

per minute, the blood pressure 158/81 mm Hg, the respiratory rate 28
breaths per minute, and the oxygen saturation 100% while the patient
was breathing ambient air. The body-mass index (the weight in
kilograms divided by the square of the height in meters) was 26.9. He
appeared to be anxious and uncomfortable and had diaphoresis. The
jugular venous pressure was 6 cm of water with a normal waveform.
28
There was no evidence of a heart murmur or rub. When the patient
was asked to indicate the location of the pain, he pointed to the
subxiphoid area; there was some tenderness in that area on palpation.
The stool was guaiac negative. The remainder of the examination was
normal.
Urinalysis revealed a specific gravity of greater than 1.040 and was
otherwise normal. A urine toxicology screen revealed cannabinoids,
and a blood toxicology screen was negative; other laboratory test
results are shown in. An electrocardiogram showed concave ST-
segment elevations (1 to 2 mm) in the inferior leads and V3 through
V6 precordial leads, along with a PR-segment elevation in lead aVR and
possible subtle PR-segment depressions imaging studies were obtained.
Dr. Matthew P. Moy: A chest radiograph was normal. The lungs were
clear, and there was no evidence of pneumothorax, cardiomegaly, or
mediastinal widening.
Dr. Dudzinski: Aspirin, clopidogrel, intravenous morphine sulfate,
lorazepam, ranitidine, aluminum hydroxide–diphenhydramine–
lidocaine–magnesium hydroxide, and intravenous infusions of heparin
and nitroglycerin were administered, and emergency coronary
angiography was arranged.

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Case study II

Carl is a 59-year-old white British male who lives in a relatively affluent

area (IMD decile 9). He reports rarely drinking and that he stopped
cigarette smoking in 2015, after ‘40 odd years’. He does little exercise
because of ‘spinal problems’ and had a paternal grandfather who ‘had a
stroke. . . he was late 60s, 70s’. Carl reveals that his friends and family
‘think I’ve got type 2 diabetes’, which was one of the reasons for
attending the health check.

Practitioner
This health check is delivered by a white British female HCA with 5
years’ experience of delivering health checks. She received training in
health checks prior to delivering them, but this primarily focused on
PoC testing, and she cannot otherwise recall the training content. The
HCA is ‘quite happy communicating’ CVD risk to patients’ and ‘primarily
do [es] it in the same way’ for all patients she sees. She prefers ‘JBS3
because it has got the heart age on it’.

The NHS Health Check

This health check lasts longer than average (> 27 minutes) and involves
more patient speaking than most (32.9% of total time), and CVD risk is
discussed for > 2 minutes. Carl’s QRISK2 is 11% (medium risk),
described as ‘a little bit higher than we’d like it to be’, and his total
cholesterol has ‘gone up a little bit’, to 4.9 mmol/l from 4.5 mmol/l (in
2016). It is suggested that Carl considers improving his good
cholesterol. His blood pressure is ‘just sort of on the higher end of
where we’d want it to be’ and his body mass index (BMI) is 28.4 kg/m 2.

What worked well

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Carl said the health check was ‘what I expected and I’m very happy,
yeah’ and was ‘now more mindful of, of what I am or I’m not doing’.
The visual presentation of heart age had the most impact on Carl. He
reported that it ‘shocked me, no it concerned me’, and made him think
‘yeah, I ought to do something about that’. He remembered ‘the
picture on that screen, the 65. . . being in the middle’ and ‘thinking
bloody hell I ain’t 65’.
The HCA manipulated Carl’s information within JBS3 to illustrate that
reducing his total cholesterol and increasing HDL cholesterol through
simple changes to his diet and physical activity levels would reduce his
CVD risk to 9.3% and lower his heart age to 62. The HCA thought ‘it’s
really good having that option’ because ‘they can actually visually see
the changes’. Carl did ‘remember that’, but had ‘already got the
message’ by that point.
Carl found a diet sheet provided by the HCA ‘helpful’. He reported
several positive behavior- and health-related outcomes:
 ‘ordered a small blood pressure monitor’, which he admitted he
had ‘never done anything like that before’
 felt ‘more mindful’, and was trying to ‘do a bit more exercise’ and
‘now looking at certain foods’
 had ‘been researching because of my concerns about diabetes’
 Diabetes was later diagnosed following a full blood check at 6
weeks post health check and Carl was prescribed metformin.

Areas to improve
Ten-year risk was not explained by the HCA and, subsequently, was not
recalled or understood by Carl. On watching the corresponding video
clip, he said that it ‘didn’t make a significant impact on me’. In the
absence of an explanation from the HCA, Carl questioned ‘exactly how

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she arrived at that percentage’, only remembering that ‘they’d like me
to be 10% or less and I’m only 11’.
The HCA did not understand and, therefore, miscommunicated event-
free survival age: ‘currently you can sort of expect to survive the age of
79 based on your lifestyle factors’. The HCA found it ‘the hardest one to
try and communicate’. In this health check, it did not create a serious
issue as Carl reported that seemed ‘a long way off, you’re looking like
20 years in the future’ and recalled thinking ‘well that’s better than
what my dad or what my grandparents had’.

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BILBOLOGHY
How Heart Disease Affects Your Body (webmd.com).

Heart disease prevention: Strategies to keep your heart healthy - Mayo Clinic

Heart disease - Diagnosis and treatment - Mayo Clinic

Case Challenge — A 32-Year-Old Man with Acute Chest Pain — NEJM

Heart Surgery - Types, Recovery, & Risks | Made for This Moment (asahq.org)

Results 5: case studies - Cardiovascular disease risk communication in NHS Health Checks using QRISK®2
and JBS3 risk calculators: the RICO qualitative and quantitative study - NCBI Bookshelf (nih.gov)

Cardiovascular disease risk factors | Ada

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