🫀 Case Study on Coronary Angioplasty (PTCA with DES Stenting)

Medical-Surgical Nursing | NANDA Nursing Care Plan Format

Interventional Cardiology | Practical File Ready

📋 Student Information

📄 Page 1 — Patient Identification Data

📄 Page 2 — Chief Complaints & Clinical History

CHIEF COMPLAINT

The patient presented to the cardiology OPD with the following complaints:

• Chest pain (Angina Pectoris) — Retrosternal heaviness/pressure type, radiating to medial aspect of left arm and occasionally to jaw. Occurring predictably on exertion — walking >500 meters, climbing 1-2 flights of stairs, and during stressful work situations (meetings, deadlines). Each episode lasting 5-10 minutes, relieved by rest and sublingual Sorbitrate 5mg within 2-3 minutes. Frequency: 2-3 episodes/day initially, now 4-5 episodes/day over the past week. CCS Class II (slight limitation of ordinary activity).
• Shortness of breath on exertion — NYHA Class II (comfortable at rest, dyspnea on ordinary physical activity). Patient reports becoming breathless after walking approximately 200 meters on level ground, whereas previously he could walk 1 kilometer without difficulty. No orthopnea, no paroxysmal nocturnal dyspnea.
• Palpitations — Occasional sensation of rapid, forceful heartbeat, usually coinciding with anginal episodes. No documented arrhythmia. No syncope or presyncope.
• Excessive sweating (diaphoresis) — Cold, clammy sweating during chest pain episodes, soaking through shirt. Resolves with pain relief.
• Fatigue and generalized weakness — Progressive over 1 month; patient reports feeling "drained" by midday; previously active at work now requiring rest periods; difficulty concentrating during afternoon meetings.
• Progressive decrease in exercise tolerance — Quantifiable reduction: walking capacity decreased from >1 kilometer to <200 meters in 2 weeks.

HISTORY OF PRESENT ILLNESS

The patient, Mr. Rajendra Prasad Sharma, a 58-year-old bank manager with a predominantly sedentary, high-stress occupational profile, presented with a 2-week history of progressive exertional angina. He was apparently well until approximately 14 days prior to admission, when he first noticed retrosternal heaviness while rushing to a meeting after climbing two flights of stairs. Initially, symptoms were mild (CCS Class I), occurring only on significant exertion (climbing >2 flights, walking >1 kilometer briskly), and were easily relieved by 2-3 minutes of rest.

Over the next 10 days, symptoms progressively worsened. The threshold for angina decreased — by day 7, chest discomfort occurred after walking just 400-500 meters on level ground. He also noted the emergence of dyspnea accompanying the chest pain. His wife observed that he had become "easily tired" and would sit down to rest after minimal activity. He self-medicated with sublingual Sorbitrate 5mg (prescribed by his family physician for suspected angina) which provided consistent relief within 2-3 minutes.

By day 12-14, his condition had deteriorated to CCS Class II-III — chest pain occurring after walking only 200 meters on level ground or climbing one flight of stairs. He also experienced one episode of angina at rest lasting approximately 8 minutes while watching television — this was particularly alarming. His wife insisted on a cardiology consultation.

At a local clinic, a resting 12-lead ECG was performed, which revealed ST-segment depression of 2mm in anterior leads (V2 through V6) with T-wave inversion — pattern consistent with anterior wall myocardial ischemia. He was promptly referred to the cardiology department at SMS Hospital, Jaipur. A transthoracic 2D Echocardiogram with Doppler was performed on 10/05/2026, which revealed: (a) Mildly reduced Left Ventricular Ejection Fraction (LVEF) of 52% (Simpson's biplane method; normal ≥55%), (b) Regional Wall Motion Abnormality — anterior wall and anteroseptal hypokinesia, (c) Normal right ventricular size and function, (d) No significant valvular abnormalities, (e) No pericardial effusion, (f) Left atrial size — upper normal limit.

Given the compelling clinical picture (progressive crescendo angina), objective evidence of ischemia on ECG, and resting LV dysfunction on Echo, the decision was made to proceed with invasive coronary angiography. On 11/05/2026, coronary angiography was performed via the right radial artery approach (6 French sheath). The angiogram revealed:

• Left Anterior Descending (LAD) Artery: 90% tubular, eccentric, calcified stenosis (Type B2 lesion according to ACC/AHA classification) in the proximal segment, just distal to the first septal perforator. The lesion was approximately 18mm in length. TIMI flow was grade 2 (delayed filling) distal to the stenosis.
• Left Circumflex (LCx) Artery: Mild (20-30%) diffuse plaque in the proximal segment. No flow-limiting stenosis. TIMI 3 flow.
• Right Coronary Artery (RCA): Dominant vessel. Mild (20%) plaque in the mid-segment. No significant stenosis. TIMI 3 flow.

The patient was diagnosed with Single Vessel Coronary Artery Disease — Critical Proximal LAD Stenosis with objective evidence of myocardial ischemia and early LV dysfunction. After discussion with the patient and family, a same-sitting ad-hoc Percutaneous Transluminal Coronary Angioplasty (PTCA) with Drug-Eluting Stent (DES) deployment was performed.

PTCA Procedure Details: The LAD lesion was crossed with a 0.014-inch guidewire. Pre-dilatation was performed with a 2.5 × 15mm semi-compliant balloon at 10-12 atmospheres. A Sirolimus-eluting Drug-Eluting Stent (DES) of dimensions 3.0mm diameter × 23mm length was deployed at 14 atmospheres and post-dilated with a 3.5mm non-compliant balloon at 16-18 atmospheres to ensure optimal stent apposition. Final angiogram showed <5% residual stenosis with TIMI 3 flow (normal antegrade flow). No procedural complications — no dissection, no side branch occlusion, no no-reflow phenomenon, no arrhythmia. The total contrast volume used was 120 mL of non-ionic, low-osmolar contrast agent (Iohexol). The procedure duration was 45 minutes. The right radial sheath was removed immediately post-procedure, and a TR Band (radial compression device) was applied with the patent hemostasis protocol. The patient was transferred to the Cardiac Care Unit in stable condition for post-procedural monitoring.

PAST MEDICAL HISTORY

• Hypertension: Diagnosed 10 years ago at age 48 during a routine health checkup. Initial BP was 156/94 mmHg. Prescribed Tablet Telmisartan 40mg once daily. Home BP monitoring shows average readings of 136/88 mmHg over the past year — not at target (<130/80 mmHg for CAD patients). Patient admits occasional missed doses (1-2 times per week) due to busy work schedule.
• Type 2 Diabetes Mellitus: Diagnosed 5 years ago at age 53. Fasting blood sugar at diagnosis was 168 mg/dL. Prescribed Tablet Metformin 500mg twice daily after meals. Recent HbA1c (done 2 weeks ago): 7.8% (target <7.0% for cardiovascular patients — suboptimal control). Patient admits poor dietary compliance — "I have a sweet tooth, I cannot resist sweets at family functions." No formal diabetic diet education received. No self-monitoring of blood glucose at home.
• Dyslipidemia: Diagnosed 3 years ago during a company health camp. Lipid profile: Total Cholesterol 240 mg/dL, LDL 158 mg/dL, HDL 36 mg/dL, Triglycerides 198 mg/dL. Prescribed Tablet Atorvastatin 20mg once daily at bedtime. Most recent lipid profile (2 weeks ago): Total Cholesterol 228 mg/dL, LDL 142 mg/dL, HDL 34 mg/dL, Triglycerides 210 mg/dL — showing inadequate control on current statin dose.
• No history of thyroid disorders, bronchial asthma, tuberculosis, epilepsy, or any chronic liver or kidney disease.
• No known drug allergies. No food allergies. Contrast dye tolerated without any allergic reaction during angiography.

PAST SURGICAL HISTORY

• No history of any major surgical intervention prior to this PTCA procedure.
• No history of general anesthesia exposure.
• No history of blood transfusion.
• Local anesthesia with 2% Lignocaine (plain) at the right radial access site — approximately 5mL infiltrated subcutaneously. Tolerated well without any complications. No allergic or adverse reactions to local anesthetic.
• This coronary angiography and PTCA represent the patient's first invasive cardiac procedure. No prior catheterization, angioplasty, or cardiac surgery.

📄 Page 3 — Family History & Composition

FAMILY HISTORY

• The patient belongs to a nuclear family consisting of himself, his wife, and their two children (son and daughter).
• Father: Mr. Ramprasad Sharma. Suffered an acute myocardial infarction (anteroseptal wall) at the age of 52 years. Underwent thrombolytic therapy (Streptokinase) at the time. Survived the acute event but developed ischemic cardiomyopathy with progressive heart failure over the next 13 years. Expired at age 65 due to decompensated congestive heart failure.
• Mother: Mrs. Kamla Devi Sharma. Diagnosed with hypertension at age 60. On regular antihypertensive medication (Amlodipine 5mg OD). Currently alive at age 80. Also has mild osteoarthritis of both knees. No history of cardiac events. No diabetes.
• Younger Brother: Mr. Rameshwar Prasad Sharma, age 50 (2 years younger than patient). Diagnosed with coronary artery disease (triple vessel disease) at age 50 during evaluation for exertional dyspnea. Underwent elective Coronary Artery Bypass Grafting (CABG × 3 grafts — LIMA to LAD, SVG to OM, SVG to PDA) at age 52 at a private hospital in Delhi. Currently on secondary prevention medications and doing well. His diagnosis was a major motivating factor for the patient to seek cardiac evaluation.
• Younger Sister: Mrs. Sunita Devi, age 54. Married, living in Udaipur. No known comorbidities. Last health checkup (1 year ago) — BP 124/78, fasting blood sugar 98 mg/dL. Advised to undergo cardiovascular risk screening given strong family history but has not done so yet.
• Summary: There is a strong, unequivocal family history of premature, aggressive coronary artery disease. Both the father (MI at 52) and brother (CABG at 52) had significant clinical CAD manifesting in their early 50s. This places the patient in a very high-risk category for genetic/familial predisposition. Both of the patient's children (son age 28, daughter age 24) will require early and aggressive primary prevention cardiovascular risk screening and lifestyle counseling.
• No known history of genetic disorders (e.g., Marfan syndrome, Ehlers-Danlos, familial hypercholesterolemia though lipid profiles suggest possible heterozygous FH), congenital heart diseases, or hereditary cardiomyopathies in the family.

FAMILY COMPOSITION

FAMILY TREE

📄 Page 4 — Dietary, Personal, Socio-Economic & Environmental History

DIETARY HISTORY

• Type of Diet: Mixed, predominantly vegetarian with occasional non-vegetarian meals (chicken curry or fish fry approximately once per week).
• High-Risk Dietary Practices: The patient's diet is characteristically high in saturated fats and trans fats. He consumes full-cream buffalo milk (approximately 500mL daily in tea and as milk). Regular use of ghee (clarified butter) as topping on rotis and dal — approximately 2-3 teaspoons per meal. Deep-fried foods are consumed 3-4 times per week — pakoras (onion fritters), samosas, kachoris, and puris are regular items in his diet. He has a particular fondness for fried snacks with evening tea.
• Sodium Intake: Very high. He habitually adds extra salt to food at the table ("food tastes bland without salt"). Consumes pickles (mango, lemon) with almost every meal. Enjoys namkeen (salted Indian snacks), papad, and chips as evening snacks. Estimated daily sodium intake exceeds 4-5 grams (recommended <2 grams for cardiac patients).
• Sugar and Refined Carbohydrates: High consumption. Adds 3 teaspoons of sugar to each cup of tea (drinks 4-5 cups daily = 12-15 teaspoons of sugar/day from tea alone). Has a strong preference for sweets — rasgulla, gulab jamun, jalebi consumed 2-3 times per week. Regular consumption of white rice, white bread (refined flour), and potatoes.
• Fiber Intake: Low. Minimal consumption of fresh fruits (occasional banana or apple — not daily). Vegetable intake is moderate but often overcooked (traditional Indian cooking), which depletes fiber and nutrients. No whole grains — prefers refined wheat flour (maida) products over whole wheat. No salads in diet.
• Caffeine: High. Drinks 4-5 cups of full-cream milk tea daily. Also consumes 1-2 cups of instant coffee at office.
• Meal Timing: Irregular due to work commitments. Often skips breakfast or has only tea and biscuits. Lunch timing varies between 1:00-3:00 PM depending on meetings. Dinner is typically late — 9:30-10:30 PM. Frequently eats dinner while watching television, unaware of portion sizes.
• Fluid Intake: Adequate — approximately 2-2.5 liters per day including water, tea, coffee, and buttermilk (chaas). No history of food allergy.

PERSONAL HISTORY

• Sleep Pattern: Sleeps approximately 5-6 hours per night (11:00 PM to 5:00 AM). Reports difficulty falling asleep ("my mind keeps racing with office worries"). Sleep is often interrupted — wakes up 1-2 times to urinate (nocturia). Does not feel refreshed in the morning. No history of using sleep medications. Wife reports he snores loudly and sometimes appears to stop breathing during sleep (possible obstructive sleep apnea — undiagnosed).
• Appetite: Generally good; however, slightly reduced since the onset of angina symptoms 2 weeks ago. Reports early satiety and mild post-prandial bloating.
• Bowel Habit: Regular, once daily in the morning. Stool consistency — normal (Bristol Stool Chart Type 3-4). However, occasionally complains of constipation (hard stools) when traveling or during particularly stressful periods at work — attributed to low fiber intake and inadequate hydration during those times.
• Bladder Habit: Frequency — 6-7 times during the day, 1-2 times at night (nocturia). No dysuria, urgency, or hesitancy. Nocturia may be related to: (a) poorly controlled diabetes (osmotic diuresis from glycosuria if blood sugar exceeds renal threshold ~180 mg/dL), (b) hypertension (pressure diuresis), (c) early diabetic nephropathy (impaired renal concentrating ability).
• Habits/Addictions: (a) Smoking: Former smoker. Smoked approximately 10 cigarettes per day for 20 years (20 pack-years). Quit 2 years ago at age 56 after his brother's CABG surgery served as a "wake-up call." However, he admits to occasional "slip-ups" — 1-2 cigarettes during social gatherings or periods of high stress (approximately once every 2-3 months). He has never used any formal smoking cessation aids (nicotine replacement, bupropion, varenicline) — quit "cold turkey." (b) Alcohol: Occasional social drinker. Consumes whiskey — 2-3 standard drinks (60-90 mL) on weekends, primarily during social gatherings or dinners with colleagues. No history of binge drinking or alcohol dependence. (c) Recreational Drugs: None.
• Activity Level and Exercise: Sedentary. Occupation requires prolonged sitting — approximately 8-10 hours daily at a desk (computer work, meetings, phone calls). Commute to work is by car (30 minutes each way). Post-retirement planning was to start a walking routine, but "never got around to it." No regular exercise program. Occasionally walks in the neighborhood park on weekends but not consistent. Does not use a fitness tracker or pedometer. Hobbies are sedentary — reading newspapers, watching television (2-3 hours in the evening), playing cards with friends on weekends.
• Allergy History: No known drug allergies. No known food allergies. No history of allergic rhinitis, asthma, or eczema. Contrast dye (Iohexol) administered during angiography without any allergic reaction.
• Anthropometric Measurements: Height: 170 cm. Weight: 85 kg. BMI: 29.4 kg/m² (Overweight — Class I Obesity according to WHO Asia-Pacific guidelines: BMI ≥25 = obesity). Waist Circumference: 104 cm (Abdominal obesity — central adiposity; significantly elevated risk: ≥90 cm for South Asian males). Waist-Hip Ratio: 0.98 (substantially increased cardiovascular risk).

SOCIO-ECONOMIC HISTORY

• The patient belongs to an upper-middle-class socioeconomic background.
• Annual Family Income: Approximately ₹8,00,000 per year (₹66,000 per month) — combining the patient's bank manager salary (₹55,000/month) and the son's contribution as a software engineer (₹25,000/month). The patient is the primary breadwinner.
• Health Insurance: Covered under the Central Government Health Scheme (CGHS) as a public sector bank employee. Additionally has a private family floater health insurance policy with coverage of ₹5,00,000. The PTCA procedure and hospital stay are expected to be largely covered by insurance with minimal out-of-pocket expenses.
• Financial Concerns: Despite insurance coverage, the patient expressed concern about potential loss of income during the recovery period (anticipated 2-4 weeks leave from work). He is worried about meeting household expenses, his daughter's ongoing medical education fees, and the cost of lifelong medications (particularly Clopidogrel, which is relatively expensive). The social worker was consulted for potential financial assistance programs.
• Family Dynamics: Stable, supportive nuclear family. Wife is the primary caregiver and emotional support. Son works in Bangalore but has taken leave to be with the patient. Daughter is a final-year MBBS student and serves as a valuable resource — she helps explain medical concepts to the parents in simple Hindi. Family appears cohesive and motivated to support the patient's recovery and lifestyle changes.

ENVIRONMENTAL HISTORY

• Housing: The family owns a well-constructed pucca (concrete) house in a residential colony in Vaishali Nagar, Jaipur. The house has 3 bedrooms, a living room, kitchen, and 2 bathrooms. Adequate ventilation with windows in all rooms. Natural lighting is good. No dampness or mold issues.
• Cooking Fuel: Uses Liquefied Petroleum Gas (LPG) for cooking — a clean fuel with no indoor air pollution. No exposure to biomass fuel (wood, cow dung, crop residue) which is a known cardiovascular risk factor in rural populations.
• Drinking Water: Reverse Osmosis (RO) purified water is used for drinking and cooking. Safe, potable water supply from municipal corporation.
• Sanitation: Adequate sanitation facilities — 2 bathrooms with running water, flush toilets. Personal hygiene maintained.
• Environmental Exposures: No occupational or environmental exposure to industrial chemicals, heavy metals, radiation, or air pollution beyond the general ambient air pollution in Jaipur (moderate levels of particulate matter). No history of pesticide or herbicide exposure.
• Living Environment: The house and surrounding neighborhood are clean, with access to parks, markets, and medical facilities. No major environmental health hazards identified.

📄 Page 5 & 6 — Physical Examination (Head-to-Toe)

GENERAL CONDITION

Patient is conscious, alert, and oriented to time (correctly states date and day), place (hospital, ward), and person (self and family members). He is cooperative with healthcare staff, maintains eye contact, and responds appropriately to questions. Appears mildly anxious — repeatedly asks about prognosis, stent durability, and timeline for return to work. Posture is comfortable in semi-Fowler's position (head elevated 30-45°). Personal hygiene is well-maintained. Dressed in hospital gown with right wrist dressing visible.

VITAL SIGNS (Post-Procedure Day 1 — 12/05/2026, 8:00 AM)

• Temperature: 98.6°F (37.0°C) — Afebrile, oral route
• Heart Rate/Pulse: 74 beats per minute, regular rhythm, normal volume, right radial pulse strong and equal to left
• Respiratory Rate: 16 breaths per minute, regular rhythm, normal depth, no use of accessory muscles
• Blood Pressure: 130/82 mmHg (right arm, sitting position, appropriate cuff size)
• Oxygen Saturation (SpO₂): 98% on room air (no supplemental oxygen)
• Pain Score: 0/10 chest (no chest pain); 1/10 right wrist (mild tenderness at access site only on palpation)
• Blood Sugar (Capillary): 142 mg/dL (fasting — pre-breakfast check)

GENERAL APPEARANCE

• Body Build: Endomorphic — stocky build with central obesity (pot-belly appearance)
• Posture: Comfortable, resting semi-recumbent; right wrist kept extended and still
• Activity Level: On bed rest as per post-PCI protocol; can move left arm and both legs freely; right wrist immobilized
• Speech: Clear, coherent, normal rate and volume; speaks Hindi fluently with some English; anxious undertone
• Signs of Distress: Mild anxiety evident (furrowed brow, occasional sighing, repeated questions); no acute distress (no grimacing, no diaphoresis, no tachypnea)
• Facial Expression: Anxious but hopeful; smiles when family is present

SYSTEMIC EXAMINATION — HEAD TO TOE

📄 Page 7 — Vital Signs Monitoring Record

📄 Page 8 — Diagnostic Investigations

📄 Page 9 — Medical Management (Drug Chart)

📄 Page 10 — Disease Introduction, Etiology & Pathophysiology

INTRODUCTION

Coronary Artery Disease (CAD) is the leading cause of death globally, characterized by atherosclerotic narrowing or occlusion of the epicardial coronary arteries. CAD exists on a clinical spectrum from stable angina to acute coronary syndromes (unstable angina, NSTEMI, STEMI). Percutaneous Transluminal Coronary Angioplasty (PTCA) with Drug-Eluting Stent (DES) implantation is a cornerstone revascularization strategy for patients with significant obstructive CAD and objective evidence of ischemia. Unlike bare-metal stents (BMS), DES platforms are coated with antiproliferative drugs (Sirolimus, Everolimus, Paclitaxel, Zotarolimus) that are eluted over weeks to months, significantly reducing the incidence of in-stent restenosis (ISR) from 20-30% (BMS era) to <5-10% (DES era). The trade-off is the requirement for prolonged dual antiplatelet therapy (DAPT) — typically 6-12 months — to prevent the dreaded complication of stent thrombosis, a catastrophic event with 20-40% mortality.

ETIOLOGY

Primary Cause: Atherosclerosis — a chronic, progressive, systemic inflammatory disease of the arterial wall. Modifiable Risk Factors: Hypertension (endothelial shear stress), Diabetes Mellitus (advanced glycation end-products accelerate atherogenesis; CAD equivalent), Dyslipidemia (elevated LDL, low HDL, high triglycerides), Smoking (endothelial dysfunction, pro-thrombotic state, carbon monoxide-induced hypoxia, HDL reduction), Obesity (adipokine-mediated inflammation, insulin resistance), Physical inactivity, Psychosocial stress (sympathetic activation, cortisol, platelet reactivity). Non-Modifiable Risk Factors: Age (>45 males, >55 females), Male gender, Family history of premature CAD (first-degree relative <55 male, <65 female), South Asian ethnicity (3-4× higher risk independent of traditional RFs).

PATHOPHYSIOLOGY

1. Atherosclerosis Initiation: Endothelial dysfunction (triggered by HTN, smoking, hyperlipidemia, DM) → Increased permeability to LDL → LDL influx into subendothelial intima → LDL oxidation (oxLDL) → Pro-inflammatory → Upregulation of adhesion molecules (VCAM-1, ICAM-1) on endothelial surface → Monocyte adhesion and transmigration into intima → Monocyte differentiation into macrophages → Macrophages express scavenger receptors (SR-A, CD36) → Unregulated uptake of oxLDL → Foam cell formation → Fatty streak (earliest visible lesion).

2. Plaque Progression: Foam cells secrete pro-inflammatory cytokines (TNF-α, IL-1β, IL-6), chemokines (MCP-1), and growth factors (PDGF, FGF) → Smooth muscle cell (SMC) migration from media to intima → SMC proliferation and phenotype switching (contractile → synthetic) → Extracellular matrix (ECM) production (collagen type I and III, elastin, proteoglycans) → Formation of fibrous cap overlying lipid-rich necrotic core → Mature fibroatheromatous plaque → Progressive luminal narrowing → Flow-limiting stenosis → Demand-supply mismatch → Myocardial ischemia → Clinical angina.

3. Plaque Rupture and ACS: Thin-cap fibroatheroma (TCFA) — large necrotic core (>40% plaque volume), thin fibrous cap (<65 μm), intense macrophage infiltration at shoulder regions, paucity of SMCs → Matrix metalloproteinases (MMP-2, MMP-9) secreted by macrophages degrade collagen in fibrous cap → Cap weakening → Sudden hemodynamic stress (BP surge, sympathetic activation) → Plaque rupture → Exposure of thrombogenic subendothelial matrix (collagen, tissue factor, von Willebrand factor) to flowing blood → Platelet adhesion (GP Ib-IX-V + vWF), activation (shape change, degranulation — ADP, TXA₂, serotonin release), aggregation (GP IIb/IIIa receptor + fibrinogen cross-linking) → Simultaneous coagulation cascade activation (tissue factor + Factor VIIa → extrinsic pathway → thrombin burst → fibrinogen → fibrin) → Occlusive thrombus → Complete vessel occlusion → STEMI.

4. PTCA and Stenting Mechanism: Guidewire crosses the stenosis → Balloon inflation at 10-18 atmospheres → Three mechanisms of lumen gain: (a) Plaque compression (minor contribution), (b) Plaque redistribution — axial and longitudinal displacement, (c) Vessel wall stretching and overexpansion — controlled medial and adventitial stretching → Barotrauma to endothelium → Denudation of endothelial lining → Exposure of subendothelial matrix → Platelet deposition and activation → Risk of acute/subacute stent thrombosis (mitigated by DAPT) → DES elutes antiproliferative drug (Sirolimus) over 30-90 days → Sirolimus inhibits mTOR (mammalian Target of Rapamycin) → Cell cycle arrest at G1→S phase transition → Inhibition of SMC proliferation and migration → Prevention of neointimal hyperplasia → Reduced in-stent restenosis → Stent provides mechanical scaffolding → Maintains vessel patency → Endothelialization of stent struts occurs over 3-6 months → Completion of healing.

📄 Page 11 — Clinical Manifestations, Diagnostic & Medical Management

CLINICAL MANIFESTATIONS

• Chest Pain (Angina Pectoris): Retrosternal heaviness/pressure; radiating to left arm, jaw; exertional; CCS Class II-III; relieved by rest/nitrates; crescendo pattern.
• Dyspnea on Exertion: NYHA Class II; progressive; due to transient LV dysfunction during ischemia (ischemic mitral regurgitation, diastolic dysfunction).
• Palpitations: Sensation of forceful heartbeat during angina; sympathetic activation.
• Diaphoresis: Cold, clammy sweating during angina; sympathetic nervous system activation.
• Fatigue: Generalized; due to reduced cardiac reserve and deconditioning.
• ECG Changes: ST-segment depression (subendocardial ischemia); T-wave inversion; normalized post-revascularization.

DIAGNOSTIC EVALUATION

• 12-Lead ECG: ST depression V2-V6 — anterior wall ischemia (resolved post-PCI).
• Cardiac Biomarkers: Troponin I 18 ng/L (normal) — rules out acute MI; distinguishes unstable angina from NSTEMI.
• 2D Echocardiography: LVEF 52% (mildly reduced); anterior wall hypokinesia; no valvular disease.
• Coronary Angiography: Gold standard — 90% proximal LAD stenosis; RCA and LCx with mild disease.
• Lipid Profile: LDL 142 (critically elevated for CAD); HDL 34 (low); TG 210 (elevated).
• Glycemic Assessment: FBS 142; HbA1c 7.8% (uncontrolled DM).

MEDICAL MANAGEMENT

• Revascularization: PTCA + DES (Sirolimus-eluting 3.0×23mm) to LAD — successful; TIMI 3 flow; <5% residual stenosis.
• Dual Antiplatelet Therapy (DAPT): Aspirin 150mg OD (lifelong) + Clopidogrel 75mg OD (minimum 12 months).
• High-Intensity Statin: Atorvastatin 40mg OD HS — target LDL <70 mg/dL.
• Beta-Blocker: Metoprolol 25mg BD — reduces myocardial O₂ demand; heart rate control.
• ACE Inhibitor/ARB: Telmisartan 40mg OD — BP control; prevents ventricular remodeling.
• Glycemic Control: Metformin 500mg BD; target HbA1c <7.0%.
• CIN Prophylaxis: IV Normal Saline 1 mL/kg/hr × 12h pre and post-procedure.
• Cardiac Rehabilitation: Phase I (inpatient) → Phase II (outpatient supervised program).

📄 Page 12 — Nursing Management, Health Education, Prognosis & Conclusion

NURSING MANAGEMENT

• 1. Cardiac Monitoring: Continuous ECG monitoring in CCU — observe HR, rhythm, ST segment changes. Early detection of stent thrombosis (ST re-elevation), arrhythmias (VT, VF, AF), and bradyarrhythmias.
• 2. Pain Assessment: Assess chest pain every 2 hours and PRN — location, quality, radiation, severity (0-10), associated symptoms (diaphoresis, dyspnea, nausea). Immediately report any chest pain — STAT 12-lead ECG and notify cardiologist.
• 3. Access Site Care (Right Radial): Assess every 15 min × 4, every 30 min × 2, every 1 hour × 4, then every 4 hours. Check for: Bleeding (active, oozing), Hematoma (measure and mark borders if expanding), Neurovascular status (color — pink vs pale; temperature — warm vs cool; capillary refill — <3 sec; sensation — normal vs numbness/tingling; movement — able to move fingers vs unable). Maintain TR Band with patent hemostasis — ensure radial pulse palpable or Doppler-positive. Keep right wrist straight and immobilized for 6 hours. After TR Band removal: Small adhesive dressing applied; keep site clean and dry for 24 hours.
• 4. DAPT Administration: Administer Aspirin 150mg and Clopidogrel 75mg at the same time daily — STRICTLY ON TIME. Never miss a dose. Educate patient about critical importance of DAPT compliance — premature discontinuation = stent thrombosis risk. Monitor for bleeding signs — gum bleeding, epistaxis, easy bruising, black/tarry stools, hematuria.
• 5. CIN Prevention: Monitor urine output hourly — maintain >0.5 mL/kg/hr (>40 mL/hr). Encourage oral fluids once permitted. Monitor serum creatinine at 24 and 48 hours post-procedure.
• 6. Vital Signs Monitoring: Per post-PCI protocol — every 15 min × 4, every 30 min × 2, every 1 hour × 4, then every 4 hours. Report: Hypotension (SBP <90), Hypertension (SBP >160), Tachycardia (>100), Bradycardia (<50), Desaturation (SpO₂ <94%).
• 7. Bed Rest and Mobilization: Complete bed rest for 6 hours post-sheath removal. Right wrist immobilized. After 6 hours: Gradual mobilization — sit in chair, stand, walk to bathroom with assistance. Avoid using right hand for weight-bearing activities for 48 hours.
• 8. Psychological Support: Acknowledge anxiety; provide clear, honest information about procedure success and prognosis; involve family in care; teach relaxation techniques (deep breathing).

HEALTH EDUCATION

• DAPT Compliance (MOST CRITICAL): NEVER STOP Aspirin or Clopidogrel without cardiologist approval. Aspirin — lifelong. Clopidogrel — minimum 12 months. Use pill box + phone alarms. Keep medication card in wallet.
• Cardiac Diet: Low saturated fat, low salt (<2g/day), Mediterranean diet. DO's: Fruits, vegetables, whole grains, fish, nuts, olive oil. DON'Ts: Fried foods, ghee/butter, red meat, processed foods, excess salt, sugar.
• Smoking Cessation: Complete and permanent — ZERO tobacco. Avoid passive smoking.
• Physical Activity: Start with 5-10 min walks, 2-3 times daily. Gradually increase. Enroll in Phase II cardiac rehabilitation.
• Warning Signs: Report immediately: Chest pain at rest, dyspnea, palpitations, black stools, severe headache, wrist swelling.
• Follow-Up: Cardiologist — 2 weeks. Lipid profile + HbA1c — 4-6 weeks. Echo — 3 months. TMT — 6 months. Annual check-up lifelong.

PROGNOSIS

With successful PTCA + DES deployment and optimal medical therapy, the prognosis of single-vessel CAD is excellent. DES patency rates exceed 90% at 1 year and 85% at 5 years. The patient's long-term outcomes depend critically on DAPT compliance, aggressive risk factor modification (LDL <70, HbA1c <7%, BP <130/80, smoking cessation, weight loss), regular cardiac follow-up, and completion of cardiac rehabilitation. Premature DAPT discontinuation remains the single greatest modifiable risk for stent thrombosis.

CONCLUSION

This case study presents Mr. Rajendra Prasad Sharma, a 58-year-old male with multiple cardiovascular risk factors who underwent successful PTCA with DES for critical proximal LAD stenosis. Comprehensive nursing care — from vigilant post-procedural monitoring to thorough patient education — is essential for preventing complications (stent thrombosis, bleeding, CIN), promoting recovery, and empowering lifelong secondary prevention. The nurse serves as clinician, educator, counselor, and care coordinator, ensuring the patient transitions from an acute cardiac event to a lifetime of heart-healthy living.

📄 Page 13 — NANDA Nursing Diagnoses

📄 Page 14-16 — Nursing Care Plans (NANDA Format)

Nursing Care Plan — 1: Risk for Decreased Cardiac Tissue Perfusion

Nursing Care Plan — 2: Risk for Bleeding (Access Site)

Nursing Care Plan — 3: Deficient Knowledge

📄 Page 17 — Discharge Summary

Mr. Rajendra Prasad Sharma, a 58-year-old male bank manager with multiple cardiovascular risk factors (hypertension ×10 years, type 2 diabetes mellitus ×5 years, dyslipidemia, ex-smoker, overweight BMI 29.4, sedentary lifestyle, strong family history of premature CAD), presented with a 2-week history of progressive crescendo angina (CCS Class II-III) and dyspnea on exertion (NYHA Class II). ECG revealed anterior wall ischemia (ST depression V2-V6). 2D Echocardiogram showed mildly reduced LVEF (52%) with anterior wall hypokinesia. Coronary angiography via right radial approach on 11/05/2026 revealed critical single-vessel CAD — 90% tubular, eccentric, calcified (Type B2) stenosis in the proximal LAD artery. RCA and LCx showed only mild non-obstructive disease. Same-sitting ad-hoc PTCA with Drug-Eluting Stent (DES — Sirolimus-eluting, 3.0 × 23 mm) was successfully deployed with excellent angiographic result (<5% residual stenosis, TIMI 3 flow). The procedure was uncomplicated — no dissection, no side branch occlusion, no no-reflow, no arrhythmia. Total contrast: 120 mL Iohexol. TR Band applied with patent hemostasis protocol. The patient was monitored in CCU for 24 hours post-procedure.

Hospital course was uneventful. The patient remained hemodynamically stable throughout — no chest pain, no ECG changes, no arrhythmias, no bleeding or hematoma at access site, no contrast-induced nephropathy (creatinine stable at 1.1→1.2→1.1 mg/dL). TR Band removed at 6 hours with patent hemostasis. Right hand neurovascularly intact. The patient was gradually mobilized starting Day 1. He received comprehensive nursing education over 3 structured teaching sessions covering DAPT, cardiac diet, lifestyle modification, smoking cessation, warning signs, cardiac rehabilitation, and follow-up care. The patient and his wife (primary caregiver) demonstrated understanding of all discharge instructions. He is being discharged on Post-Procedure Day 2 (13/05/2026) in stable condition on guideline-directed medical therapy including DAPT (Aspirin 150mg OD lifelong + Clopidogrel 75mg OD for minimum 12 months), high-intensity statin (Atorvastatin 40mg OD HS), beta-blocker (Metoprolol 25mg BD), ARB (Telmisartan 40mg OD), and antidiabetic medication (Metformin 500mg BD). He has been enrolled in the Phase II outpatient cardiac rehabilitation program with first cardiologist follow-up in 2 weeks.

At discharge, the patient is STRONGLY advised to:

• NEVER STOP Aspirin or Clopidogrel without explicit written approval from your cardiologist. Premature DAPT discontinuation is the #1 cause of stent thrombosis, which carries a 20-40% risk of death. If any other doctor, dentist, or surgeon suggests stopping these medications, you must FIRST consult your cardiologist.
• Take ALL medications exactly as prescribed, at the same time every day. Use a weekly pill box organizer (provided at discharge). Set mobile phone alarms for medication timings. Keep an updated Medication Card in your wallet at all times listing all your drugs, doses, and timings.
• Follow strict cardiac diet: LOW SALT (<2 grams sodium per day — approximately 1 level teaspoon). Remove salt shaker from dining table. Avoid pickles, papad, namkeen, chips, canned foods, and processed foods. LOW SATURATED FAT — avoid ghee, butter, full-cream milk, red meat, organ meats, fried foods, bakery products. INCREASE: Fruits (2 servings/day), vegetables (3 servings/day), whole grains, fish (2-3 times/week), nuts (handful daily — almonds, walnuts). Use mustard oil or olive oil for cooking.
• Complete and permanent smoking cessation — ZERO tobacco in any form. Avoid passive smoking. If you have cravings or difficulty, contact the smoking cessation helpline or clinic.
• Limit alcohol — ideally complete cessation. If unavoidable, MAXIMUM 1 small drink (30mL whiskey) on occasion, not more than twice a week, and never with medications.
• Start walking — begin with 5-10 minute slow walks on level ground, 2-3 times daily. Gradually increase duration by 5 minutes each week. After 2 weeks, you can increase pace to brisk walking. Attend the Phase II Cardiac Rehabilitation program (enrollment completed; first session scheduled).
• No heavy weightlifting (>5 kilograms) with the right arm for 1 week. No driving for 48 hours after discharge. No strenuous exercise or vigorous sports for 1 week.
• Sexual activity can be resumed when you feel comfortable — usually 1-2 weeks after the procedure if you can climb 2 flights of stairs without chest pain or shortness of breath. Use less strenuous positions initially. Avoid heavy meals and alcohol before intercourse.
• Return to work — your desk job as a bank manager can be resumed after 2 weeks if you are asymptomatic and your cardiologist approves. Start with half-days if possible for the first week. Avoid excessive stress; delegate tasks; take regular breaks.
• Monitor your blood pressure at home — check 2-3 times per week and maintain a written log. Target BP: less than 130/80 mmHg.
• Monitor your blood sugar — check fasting and 2 hours after meals at least twice weekly. Maintain a log. Target fasting: 80-130 mg/dL; post-prandial: <180 mg/dL; HbA1c: <7.0%.
• Keep ALL follow-up appointments: First cardiologist visit at 2 weeks after discharge for medication review and symptom assessment. Blood tests (lipid profile, HbA1c, renal function) at 4-6 weeks after discharge. 2D Echocardiogram at 3 months to reassess LVEF and heart function. Treadmill Test (TMT/Stress Test) at 6 months to assess exercise capacity and residual ischemia. Annual comprehensive cardiac check-up lifelong.
• Get a dental check-up and maintain good oral hygiene — gum disease can affect heart health.
• Get your annual influenza vaccine and one-time pneumococcal vaccine (as recommended for cardiac patients).
• Your children (son age 28, daughter age 24) should undergo cardiovascular risk screening — lipid profile, blood sugar, blood pressure, and lifestyle counseling — given the strong family history of premature CAD.
• 🚨 CALL 108 (AMBULANCE) IMMEDIATELY AND GO TO THE NEAREST EMERGENCY ROOM IF YOU EXPERIENCE: (1) Chest pain or discomfort at rest lasting more than 5 minutes — especially if similar to your previous angina but not relieved by Sorbitrate. (2) Sudden shortness of breath or difficulty breathing. (3) Black, tarry stools (like coal tar) or vomiting blood or blood in urine — signs of internal bleeding from blood thinners. (4) Sudden severe headache with weakness or numbness on one side of the body, difficulty speaking, or vision changes — signs of stroke. (5) Rapidly expanding swelling, severe pain, or coldness at the right wrist access site. (6) Fever above 100.4°F (38°C) with chills. DO NOT DRIVE YOURSELF TO THE HOSPITAL — call an ambulance. Carry your Medication Card with you to the emergency room.

📄 Page 18 — Health Education (Detailed)

📄 Page 19 — Bibliography

1. Brunner, L.S. & Suddarth, D.S. (2022). Textbook of Medical-Surgical Nursing (15th ed.). Wolters Kluwer Health. Chapter 27: Management of Patients with Coronary Vascular Disorders, pp. 752-812.
2. NANDA International. (2024). Nursing Diagnoses: Definitions and Classification 2024-2026 (13th ed.). Thieme Medical Publishers, New York.
3. Levine, G.N., Bates, E.R., Blankenship, J.C., et al. (2023). 2023 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Journal of the American College of Cardiology (JACC), 82(4), e51-e200.
4. Thygesen, K., Alpert, J.S., Jaffe, A.S., et al. (2024). Fourth Universal Definition of Myocardial Infarction. Circulation, 138(20), e618-e651. American Heart Association.
5. Mauri, L., Kereiakes, D.J., Yeh, R.W., et al. (2024). Duration of Dual Antiplatelet Therapy After Drug-Eluting Stents: A Comprehensive Review of Current Evidence and Recommendations. New England Journal of Medicine (NEJM), 371(23), 2155-2166.
6. Mehran, R., Dangas, G.D., & Weisbord, S.D. (2023). Contrast-Associated Acute Kidney Injury — Mechanisms, Risk Prediction, and Prevention. New England Journal of Medicine (NEJM), 380(22), 2146-2155.
7. Doenges, M.E., Moorhouse, M.F., & Murr, A.C. (2024). Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span (11th ed.). F.A. Davis Company, Philadelphia.

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