Introduction to case study

Scenario

John is a 47-year-old man, whose wife died 5 years ago. Recently he has been experiencing signs of health deterioration, including high blood pressure, cold sweats and radiating chest pain to his left arm. John has kept these signs and symptoms confidential, not sharing his health issues with the family. His signs are exacerbated by continual stress, anxiety, unresolved grief and the pressures of looking after his family’s farm. He recently restarted smoking, as a coping mechanism against the stresses that he has in his life. At a recent community event, with people gathering in a well-known tavern to celebrate Easter Sunday after a church mass, John experiences an episode of shortness of breath and crushing sensations of chest pain. His cousin Alberto rushes John to the emergency department of the nearest hospital (Lismore base). Upon arrival at the hospital, the emergency doctor sees on the electrocardiogram tracing that John has developed an elevated ST myocardial infraction, which requires emergency coronary artery bypass grafting surgery (CABGX4).

The family becomes really concerned about John’s diagnosis, especially as they have always known him as a healthy, active man. John is transferred to a large tertiary hospital in Queensland so he can have his surgery within 24 hours. This news is very difficult and scary for Elisabeth. She is extremely concerned about her dad undergoing a complex surgery and very frightened about losing her father. Elisabeth starts to show signs of extreme anxiety, especially as she lost her mother at a young age. Maria, Maximo and Elisabeth decide to move to a hotel nearby so they can visit John and support him during his recovery from a complex surgery.

After his surgery John is transferred to the intensive care unit (ICU) for 48 hours. During his stay in the ICU, John struggles with his breathing due to his history of smoking. The healthcare team supports John to use an incentive spirometer and try some deep breathing exercises. He also requires a high flow of oxygen (45 litres at 45% of oxygen). During his stay at the hospital, John also experiences high levels of blood glucose. An ongoing diagnosis of coronary heart disease makes him very anxious about his surgical wound and recovery after discharge.

During visits by Elisabeth, Maria and Maximo in the post-operative phase, the family is concerned to see John connected to such an array of monitoring devices, which includes telemetry, drains, intra dwelling catheter, intra venous canula and isolated wires. The nursing and inpatient cardiac rehabilitation teams play an integral part in reassuring John and the family about discharge arrangements. On John’s last day at the hospital, he is referred to an outpatient cardiac rehabilitation program and provided with 2 follow-up appointments with cardiac surgeons and the outpatient department.

Thinking points

Cardiac rehabilitation history, inpatient, outpatient, long term:

The management of myocardial infarction (MI) has changed significantly since 1950. However, cardiac rehabilitation (CR) remains underutilised treatment. The figure below shows the history of CR:

Figure 1:

History of cardiac rehabilitation

Now patients who survive an MI not only require a reperfusion similar to what John has undergone, but also an inpatient cardiac rehabilitation intervention that starts pre-operatively, continues after surgery and then after discharge (Nasrawi et al. 2022).

• Phase 1 cardiac rehabilitation focuses on introducing mobilisation to patients and required information for discharge and recovery.
• Phase 2 is an outpatient hospital-based program that includes a group and runs for 6 to 12 weeks.
• Phase 3 is known as the maintenance phase and is usually around 4 to 6 months where patients learn how to continue their exercise regime, risk factor modification and return to work and their daily lifestyle.

Key information and links to other resources

• Heart Foundation: What is coronary heart disease?
• Heart Foundation: Find a cardiac rehabilitation service near you
• Diabetes Australia

What is a myocardial infarction?

John experiences a feeling of crushing chest pain or in medical terms an ‘unstable angina’. His angina is associated with atherosclerosis plaque, thrombus and was not relieved by rest. The occlusion escalates to an ST-elevation myocardial infarction.

Symptoms of a myocardial infarction, or ‘heart attack’ can be different for each person, ranging from serious to mild. The most commons symptoms include:

1. Pain or tightness in one of these areas: chest, arms, shoulders, neck or jaw.
2. Shortness of breath, feeling dizzy, sweaty or nausea.

For example, this flyer should be available in every household, especially in John’s house, to detect early signs and trigger an early response. The Heart Foundation website has many resources that can assist patients and families to manage coronary artery disease, including videos and flyers in various languages:

• Heart attack warning signs

Case study 2 summary

John’s case covers the importance of early detection of signs of myocardial infarction and early management to improve health outcomes. While reperfusion therapy is vital to increasing chances of survival, cardiac rehabilitation, or, in more inclusive terms, secondary prevention, is essential to implementing lifelong preventative strategies.

References

Australian Institute of Health and Welfare. (2023). Heart, stroke and vascular disease: Australian facts. https://www.aihw.gov.au/reports/cvd/092/hsvd-facts/contents/treatment-and-management/hospital-care-and-procedures

Nasrawi, D., Latimer, S., Massey, D., & Gillespie, B. M. (2023). Delivery, barriers, and enablers to patient participation in inpatient cardiac rehabilitation following cardiac surgery: An integrative review. Australian Critical Care, 36(3), 420–430. https://doi.org/10.1016/j.aucc.2022.01.007

Redfern, J., Gallagher, R., O’Neil, A., Grace, S. L., Bauman, A., Jennings, G., Brieger, D., & Briffa, T. (2022). Historical context of cardiac rehabilitation: Learning from the past to move to the future. Frontiers in Cardiovascular Medicine, 9, Article 842567. https://doi.org/10.3389/fcvm.2022.842567

Suggested readings

Walker, R., Lin, F., Chaboyer, W., Latimer, S., Eskes, A., Clayton, C., Murphy, C., Sladdin, I., Bull, C., & Gillespie, B. (2020). Identifying surgical wound care priorities from the perspectives of clinicians and health consumers in an Australian private healthcare context: A case study. Wound Practice & Research, 28(1), 17–21. https://doi.org/10.33235/wpr.28.1.17-21