Myocardial Infarction: Cardiovascular Case Study

Specific Diagnosis

Myocardial Infarction of unspecified site. ST-Elevation Myocardial Infarction (STEMI) is referred to the clinical presentation of the ST-segment elevations. The patient’s major arteries are blocked, and the ECG detects abnormalities. The ST segment is the flat, isoelectric section of the ECG between the end of the S wave (the J point) and the beginning of the T wave. ST depression is seen in leads 1, aVL.

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The disease is life-threatening and associated with atherosclerosis, putting the patient at risk for developing ventricular fibrillation, which might lead to a massive heart attack (a sudden cardiac arrest). The signs and symptoms of STEMI discovered in the patient include: chest pain and discomfort, nausea and vomiting, dizziness, shortness of breath, weakness, and diaphoresis (unexplained by the ambient temperature) (Li et al., 2015). The patient experiences denial and dismisses the symptoms of the disease, which made him delay seeking care for a long period of time. He also claims feeling well at the present moment. For successful treatment, it is important to know the amount of time the patient’s heart artery has been blocked. In the event of failure of medication treatment, he may require coronary artery bypass graft (an open heart surgery).

ICD 10 code

I21.3 (myocardial infarction of unspecified site) is a billable ICD-10-CM code necessary to state the diagnosis for the purposes of reimbursement (“ICD-10-CM Diagnosis Code I21.3,” 2018).

Clinical Information: Necrosis of the myocardium, resulting from the interrupted supply of the blood to the affected area. The condition is characterized by the chest pain, sweating, and dyspnea; the onset of the symptoms is rapid and severe (“ICD-10-CM Diagnosis Code I21.3,” 2018).

The code is applicable to the following conditions:

  • Transmural (Q wave) myocardial infarction NOS
  • Acute transmural myocardial infarction of unspecified site
  • Type 1 ST elevation myocardial infarction of unspecified site (“ICD-10-CM Diagnosis Code I21.3,” 2018).

Approximate Synonyms:

  • Acute myocardial infarction
  • Acute myocardial infarction due to occlusion of left coronary artery
  • Acute heart attack
  • Myocardial infarction (heart attack)
  • Acute ST segment elevation myocardial infarction
  • Chordae tendineae rupture after acute heart attack
  • Hemopericardium after acute heart attack
  • History of myocardial infarction less than 4 weeks ago
  • Mural thrombus of heart, following heart attack
  • Post-infarction mural thrombus
  • Rupture of interventricular septum
  • Rupture of interventricular septum following acute myocardial infarction
  • Rupture papillary muscle complicating acute heart attack
  • Subsequent heart attack, inferior wall, within 4 weeks of previous heart attack
  • Subsequent heart attack, anterolateral wall, within 4 weeks of previous heart attack
  • Subsequent heart attack, inferolateral wall, within 4 weeks of previous heart attack
  • Subsequent heart attack, posterior wall, within 4 weeks of previous heart attack
  • Subsequent non-ST elevation myocardial infarction, within 4 weeks of previous myocardial infarction
  • Subsequent ST elevation inferolateral wall myocardial infarction, within 4 weeks of previous myocardial infarction
  • Subsequent ST elevation anterolateral wall myocardial infarction, within 4 weeks of previous myocardial infarction
  • Subsequent ST elevation anterior wall myocardial infarction, within 4 weeks of previous myocardial infarction
  • Subsequent ST elevation posterior wall myocardial infarction, within 4 weeks of previous myocardial infarction
  • Subsequent st elevation inferior wall myocardial infarction, within 4 weeks of previous myocardial infarction (“ICD-10-CM Diagnosis Code I21.3,” 2018).

Prescriptions

  • Aspirin 81 mg
    • Sig: 1tab QAM Dispense # 30 Refills 3
  • Nitroglycerin
    • Sig: 1 sublingual at onset Q5M with of maximum of 3 over 15 min Dispense # 3Refill x 1
  • Propranolol 60 mg
    • Sig: 1-tab BID Dispense 60-tabs Refill 1
  • Simvastatin 20mg
    • Sig: 1-tab QHS Dispense: 30 Refill 1

Education

The patient needs to cease smoking since smoking is one of the most powerful of all risk factors associated with STEMI. Its effect on patients is exerted much sooner than the impact of any other factor. Regardless of the age, current smokers increase their risks by 95% as compared to those who quit smoking or never smoked (Symons et al., 2016).

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Another crucial factor is weight management as the patient suffers from obesity (having a BMI of 33.5 %, which is higher than normal). He must consume low-face and low-sodium products to keep fit. Obese patients diagnosed with STEMI have longer treatment time delays and higher hospital and long-term mortality (Li et al., 2015).

Other recommendations include: 1) keeping Nitroglycerin in the dark area away from sun exposure; 2) taking medications as ordered; 3) avoiding self-treatment; 4) monitoring pulse and blood pressure. Since STEMI is one of the gravest heart conditions, it is crucial for the patient to follow the prescribed treatment strategy. In case of taking other medications, he may increase the risk of using those that cannot be taken together for considerable safety reasons (they might cause a massive drop in the patient’s blood pressure, which can be lethal). It is also possible that self-selected medications will affect the potency of the ordered ones, which will let the patient’s major symptoms go untreated. Inaccurate dosages are fraught with other life-threatening consequences as they might accidentally result in an overdose.

Activity

The patient needs a regular physical activity for a minimum 30 minutes 5 times a week as tolerated. This schedule is beneficial not only for treating obesity but also for improving the patient’s well-being after STEMI. It has been proven that physical exercises reduce the risk of a repeated attack (despite the common delusion that bed rest is the only possible regimen for such patients). If the patient feels unwell exercising, 30-60 minutes of moderate activity can be spread into several segments and be repeated throughout the day. The activities allowed include walking, cycling, jogging, and resistance training (if the patient tolerates it well). Daily walking is recommended immediately after the discharge. However, it is not safe to follow an unsupervised work-out program since the patient can over-exercise and do harm to his health (especially taking into the account the fact that he denies the problem and has a self-perception of a healthy person). STEMI patients require cardiac rehabilitation programs to modify risk factors (Jolly et al., 2016). Such programs typically cover not only the physical but also the psychological aftermath of STEMI.

Follow-up

The patient requires a follow-up 1-2 weeks or sooner depending on symptoms. In the majority of patients hospitalized with STEMI, it is hard to achieve long-term adherence to prescribed medications even despite the fact that they allow lowering risks of another attack. That makes it particularly important to attend follow-up appointments within the first two weeks of discharge and later (Jolly et al., 2016).

Referrals

In the event of repeated symptoms, the patient must visit an emergency room. Once STEMI has been diagnosed, it is vital to avoid delays in treatment. In case of emergency, staff members are to implement initial therapies quickly. The patient’s outcomes will directly depend on the amount of time it will take them to render aid. The patient must also see a cardiologist in approximately 1 week for ECG and examination to see whether medications are effective.

References

ICD-10-CM Diagnosis Code I21.3. (2018). Web.

Jolly, S. S., Cairns, J. A., Yusuf, S., Rokoss, M. J., Gao, P., Meeks, B.,… Chowdhary, S. (2016). Outcomes after thrombus aspiration for ST elevation myocardial infarction: 1-year follow-up of the prospective randomised TOTAL trial. The Lancet, 387(10014), 127-135.

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Li, J., Li, X., Wang, Q., Hu, S., Wang, Y., Masoudi, F. A.,… China PEACE Collaborative Group. (2015). ST-segment elevation myocardial infarction in China from 2001 to 2011 (the China PEACE-Retrospective Acute Myocardial Infarction Study): A retrospective analysis of hospital data. The Lancet, 385(9966), 441-451.

Symons, R., Masci, P. G., Francone, M., Claus, P., Barison, A., Carbone, I.,… Bogaert, J. (2016). Impact of active smoking on myocardial infarction severity in reperfused ST-segment elevation myocardial infarction patients: The smoker’s paradox revisited. European Heart Journal, 37(36), 2756-2764.

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