Management of Heart Rate and Blood Pressure of a Patient after Successful Coronary Angioplasty and Stenting: A Case Study

Abstract In this case study the persistence of hypertension in a patient after successful coronary angioplasty was assessed. Pulse and blood pressure were recorded twice daily for 33 days at random interval. The results show the patient had high blood pressure for a total of 17 days in the 33 days of study period after Coronary Angioplasty and Stenting. The patient’s blood pressure never excided above 170/90 and pulse remained normal through the study period. In the case study multiple drugs failed to control blood pressure adequately. Other external factors may play a role in failure of management of BP. Indeed the patient’s lack of lifestyle modification as per advice of the physician may play a significant role in the persistence of hypertension. The patient should seek further medical assistance from specialists and drugs should be altered to control blood pressure adequately. Further investigation might be considered to rule out secondary causes of persistent hypertension.


Introduction
During cardiac contraction the ejected blood creates a lateral pressure against the blood vessels termed "Blood pressure".If blood pressure is too high, it puts extra strain on the arteries (and heart) and this may lead to heart attacks and strokes.Having high blood pressure (hypertension) is usually asymptomatic.Blood pressure is measured in 'millimetres of mercury' (mmHg).The ideal blood pressure is below 120/80 mmHg [1][2][3] .Most adults in the UK have blood pressure readings in the range from 120/80 140/90.High blood pressure (hypertension) indicates sustained blood pressure readings at 140/90, or higher.High blood pressure is related to heart and kidney disease, and is closely linked to some forms of dementia.People from African-Caribbean and South Asian communities are at greatest risk from hypertension 4 .Blood supply of the heart is maintained by the coronary arteries.In older people, these arteries can become narrowed and hardened (known as atherosclerosis), which can cause coronary heart disease.If the flow of blood to the heart becomes restricted, it can lead to chest pain known as angina.A coronary angioplasty is a procedure used to widen blocked or narrowed coronary arteries 1 .The term 'angioplasty' means using a balloon to stretch open a narrowed or blocked artery.However, most modern angioplasty procedures are followed by insertion of a short wire-mesh tube, called a stent, into the artery 2 .The stent is left in place permanently to reestablish blood flow.The combination of coronary angioplasty with stenting is usually referred to as percutaneous coronary intervention (PCI) 6 .PCI is often used as an emergency treatment after a heart attack.Around 75,000 procedures are performed in England each year 4 .This procedure is generally safe but serious complications of the procedure include excessive bleeding, a heart attack and a stroke 5 .

Patient's History and Angioplasty
A patient of 57 years old, hypertensive (on regular antihypertensives), non-diabetic, non-alcoholic, past smoker (10 cigarettes a day for 34 years), having height of 1.72 m and weight of 80 kg was reasonably well 6 months back.Than the patient started to develop central chest discomfort which was aggravated by exertion and relived by rest.The patient also complained of loss of consciousness for one time 2 months back.Routine investigation including CBC, serum creatinine, serum electrolyte and lipid profile were done Triglyceride level was found higher than normal while potassium level was found to be low for which the patient was treated (Table 1).3) and admitted into the CCU on the same day at 23:00 hours after preliminary ECG was done in the emergency ward.
Troponin-I was measured in the CCU which was found elevated slightly (0.086 ng/ml with a reference value of up to 0.034 ng/ml) and Pro-BNP which was greatly elevated (4359.0pg/ml with a reference value of 0125 pg/ml for people aged < 75 yrs).Family history reveals both the patient's father and mother suffered from high blood pressure.Father also suffered from unstable angina and expired from HCC when he was 77 and mother died from stroke when she was 74.The patient had no previous history of CVD, CKD, or Bronchial asthma.On admission his pulse was 81 bpm while blood pressure was 140/80 mm of Hg.Heart sounds S1 & S2 was normal and lungs base was clear.After admission the patient was treated conservatively with LMWH and other antianginal drugs.A multitude of tests were done to assess the fitness of the patient for Angiogram and possible Angioplasty with stenting (Table 2).After stabilization coronary angiogram was done using local anaesthesia on 26 November 2016 and two major narrowings were found in the LCx and RCA.PCI to LCx & RCA was done adhoc.The procedure was well tolerated.There was no complication during and after the procedure.Patient's further hospital stay was uneventful.Therefore, the patient was discharged on 28 November 2016 at 11:15 hours in a stable haemodynamic condition with specific medications and advice (Table 6).With the above background this study was designed to stabilize the heart rate and blood pressure of a patient after successful PCI.Objectives 1.To manage blood pressure by applying medicines 2. To normalize heart rate along with blood pressure by applying medicines

Materials and Method
Different investigations were done at random interval to assess coronary and renal risk factors from 2014 onward (Tables 1 & 2).Radial Pulse rate was measured by palpation and BP was measured by a sphygmomanometer at 9:00 and 20:00 hours daily at random interval for 33 days.After successful angioplasty, a course of medicines were prescribed by the Intervention Cardiologist.The type and doses of medicines were as follows (Table3).Seven days (4 December 2016) after of the procedure, the patient's pulse and blood pressure was checked, which were 80 bpm and 160/90, respectively.Tablet Mitosan was added.Tablet Nitrin SR 2.6 mg was taken for 7 days while Tablet Rivotril was not taken at all as the patient believed that he had no problem with sleep.Injection Intravas was taken thrice in three consecutive days while Nitrocard spray was not used following advice of the cardiologist as further chest discomfort was not experience by the patient (Table 3).

Conclusion
Hypertension is a major risk factor in development of different cardiovascular events.Control of hypertension is crucial in reducing overall mortality and morbidity from ACS.In the study multiple drugs failed to control blood pressure adequately.Other external factors may play a role in failure of management of BP.Indeed the patients lack of lifestyle modification as per advice of the physician may play a great role in the persistence of hypertension especially in the morning.Further study is needed to verify the correlation of work related stress and uncontrolled hypertension after angioplasty and stenting.The patient should seek further medical assistance from specialists and drugs should be altered to adequately control blood pressure.Further investigation might be considered to rule out secondary causes of persistent hypertension.

Table 1 .
Investigation for assessing heart and kidney conditions before PCI in 2016 Than on 23 rd November 2016 the patient developed central chest discomfort while resting associated with sweating.The patient was given Emergency management with Tablet Ecosprin 300mg, Tablet Anclog 300mg and Anril spray 800µg sub lingually at 15:00 hours (Table

Table 2 .
Results of different tests of Blood before Coronary Angioplasty in 2016

Table 3 .
Type, rate and doses of medicines to manage

Table 6 .
Results of different tests after PCI in 2016