Strictly Clinical

Recognizing atypical angina symptoms

Jane Ramsey, age 65, is admitted to the orthopedic surgical unit after an open reduction and internal fixation of the right femur. Her past medical history includes coronary artery disease with stent placement, type 2 diabetes, mild hypertension, and recurrent urinary tract infections. Martin, the nurse assigned to her care, assists her to the bathroom. When she reports feeling dizzy, he returns her safely to bed.

History and assessment hints

Martin obtains Mrs. Ramsey’s vital signs: blood pressure 82/46 mm Hg, heart rate 89 beats/minute, respiratory rate 20 breaths/minute, blood oxygen saturation (Spo2) 92%, and temperature 37.1° C (98.8° F). The patient continues to complain of dizziness and lightheadedness. She states she occasionally has vertigo but believes her current symptoms are somewhat worse.

Call for help

Because the patient’s systolic pressure is below 90 mm Hg, Martin decides to call the nurse practitioner (NP) from the rapid response team (RRT) to evaluate her.

On the scene

When Carolyn, the NP, arrives, she finds Mrs. Ramsey complaining of gastric bloating and mild nausea. Carolyn notes she is pale, lethargic, and diaphoretic. The right femur dressing is dry and intact, and the patient’s toes are warm with brisk capillary refill. Her breath sounds are clear, her heart rate regular, and her abdomen soft with active bowel sounds. She has had no urine output this shift. Laboratory tests show a hemoglobin value of 8.2 g/dL and a blood glucose level of 264 mg/dL.

Mrs. Ramsey’s pallor seems disproportionate to her hemoglobin value. Carolyn orders a 250-mL bolus of normal saline solution, discontinues morphine, and adds acetaminophen to manage mild pain and avoid narcotic oversedation. To find the cause of hypo­tension, she reviews the patient’s history and learns she had sepsis on a previous admission. She notes Mrs. Ramsey is having atypical angina symptoms more common in females than males—fatigue, nausea, and vague epigastric discomfort. She orders cardiac biomarker tests to check for compromised myocardial perfusion, as well as lactic acid and procalcitonin levels to evaluate perfusion and sepsis risk. To check for acute myo­cardial infarction (MI), she orders a STAT 12-lead ECG. Then she leaves to discuss the case with the orthopedic surgery resident.

A short time later, she gets a call from Martin asking her to reevaluate Mrs. Ramsey for continued hypo­tension and new-onset chest pain. On arrival, she finds the patient’s systolic pressure has corrected to 91 to 110 mm Hg, but she has developed new subxiphoid chest pressure with mild nausea. The pain is nonradiating, nonpleuritic, and nonreproducible with palpation.


The 12-lead ECG shows normal sinus rhythm, an inferior infarction of undetermined age, and anterolateral ischemia. Although no elevated ST segments are present to indicate acute injury, the ECG differs from the pre­-operative ECG. The troponin test comes back at 0.76 mcg/L—a significant elevation from normal.

After consulting the orthopedic surgery resident again, Carolyn pages an AMI “call-down” to alert the cardiologist and cardiovascular lab staff that they’re needed for a percutaneous coronary intervention. She presents the case to the cardiologist, who determines the patient is having a non-ST segment elevation MI. Mrs. Ramsey is taken to the cardiovascular lab for percutaneous coronary intervention and reperfusion in just under 30 minutes from onset of the original RRT call.

Outcome

The cardiologist places a drug-eluting stent in Mrs. Ramsey’s right coronary artery to prevent in-stent restenosis. Although her course is complicated by her orthopedic surgery, she experiences no further cardiac or surgical complications during her hospital stay.

Education and follow-up

On discharge, the nurse instructs Mrs. Ramsey to notify the physician of atypical angina symptoms. She also advises her to follow the American Heart Association’s dietary and lifestyle modifications, and tells her the physician has referred her for cardiac rehabilitation. For Mrs. Ramsey, collaboration between the bedside nurse and RRT led to an optimal outcome.

Linda Benson is a member of RRT team at Bronson Methodist Hospital in Kalamazoo, Michigan.

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