Description
Case Study
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Chapter 15 Case Study 1
Subjective
Medical History
Mr. XO, aged 48 yr, with prior history of type 2 diabetes and ischemic heart disease. He
experiences angina on mild to moderate exertion, 3 to 5 METS, and his hypertension is
controlled with medication. He has a strong family history of type 2 diabetes and was
diagnosed himself 12 yr ago. Mr. XO has never smoked and has a sedentary occupation as a
store manager for a large local corporation. He walks 1 to 2 mi (1.6-3.2 km) each lunchtime,
weather permitting, Over the past 3 mo, he has started to notice increased angina and
shortness of breath when climbing two flights of stairs at work; at the top of the stairs, he
feels some moderate chest pressure that resolves in a couple of minutes after he sits down at
his desk. His primary care physician sends him for a routine exercise stress test.
Medication
Candesartan
4 mg once daily
Bisoprolol
2.5 mg nighttime
Atorvastatin
80 mg daily
Diamicron
60 mg twice daily
Isosorbide mononitrate 120 mg daily
Nicorandil
10 to 20 mg twice daily
Clopidogrel
75 mg daily
GTN spray
As required for angina
Diagnosis
Male, 48 yr old, with angina, dyslipidemia, and diabetes with a lateral infarct and family
history of premature coronary artery disease. Single-vessel coronary artery disease with small
diffusely diseased diagonal culprit not suitable for PCI and marginal for CABG.
Objective and Laboratory Data
Physical Examination Results
Resting ECG: Appears normal
Heart rate: 65 beats · min−1 and regular
Blood pressure: 110/72 mmHg
Heart and lung sounds: Suggestion of pops and crackles
Blood Chemistry Test Results
His fasting blood sugar 3 mo ago was 234 mg/dL and HbA1c was 8.7.
Other Clinical Diagnostic Test Results
Coronary Angiogram
• Procedure: Coronary and left ventricular angiogram
• Indication: 48 yr old with angina, dyslipidemia, and diabetes with a lateral infarct
and family history of premature coronary artery disease
• Technique: RFA 6 FR, JL4, JR4, and pigtail catheters
• Hemodynamics: Aorta: 109/67 mmHg; mean 81 mmHg; LV: 109/22 mmHg
1
From J.K. Ehrman, P.M. Gordon, P.S. Visich, and S.J. Keteyian, Clinical Exercise Physiology HKPropel Access,
5th ed. (Champaign, IL: Human Kinetics, 2023).
Findings
• LMCA: No stenosis
• LAD: 65% to 75% mic calcified stenosis
• Diagonal: Diffusely diseased (90%) vessel first diagonal (culprit), too small for
stent; TIMI II flow (only 1.7 mm vessel despite intracoronary GTN)
• Circumflex: 20% proximal stenosis
• RCA: Dominant, no stenosis
• Ventriculography: LVEF 45%; mid and anterolateral akinesis
Conclusion
• Single-vessel coronary artery disease with small, diffusely diseased diagonal
culprit not suitable for PCI and marginal for CABG
• Proceeded to PCI-LAD
• Medical treatment for diagonal disease
• Preoperative exercise program
• Postoperative exercise program
Exercise Test Results
No tests were conducted.
Discussion Questions
a. Are there any results from the physical examination or blood chemistry or other
diagnostic test results that may influence any recommendations for exercise or
physical activity?
b. Based on the exercise testing results, if applicable, are there any considerations
regarding the safety of exercise training for this individual?
Exercise Assessment and Plan
Some exercise prior to PCI may help his recovery post-PCI, but presurgery, Mr. XO would
be wise to limit his exercise intensity to light (20%-40% peak V̇O2 or 40%-55% HR
maximum, depending on bisoprolol effects on maximum heart rate or RPE on Borg scale [810]). He might be best advised to exercise in multiple short bouts daily (e.g., 3 × 10 min) to
accumulate his physical activity; this avoids long periods of ischemia or angina.
Postsurgery, he can resume light activity and then progress after 2 to 3 wk to longer
exercise bouts, increasing to around 15 min bouts at week 3 and adding 1 to 2 min/wk.
Eventually at 6 to 8 wk, he may start to progress to very short (30-60 s) periods of moderateintensity work if his symptoms allow.
Discussion Questions
a. Based on the information provided, what might you consider when determining
whether this patient should perform exercise training, and what benefits would you
expect to observe?
b. Are there any signs, symptoms, medications, or other items listed that would need to
be considered when assessing this patient for an exercise training program?
c. Develop a 12 wk exercise prescription for cardiorespiratory, resistance, and range of
motion training if applicable. Use the FITT principle when developing your
prescription.
2
From J.K. Ehrman, P.M. Gordon, P.S. Visich, and S.J. Keteyian, Clinical Exercise Physiology HKPropel Access,
5th ed. (Champaign, IL: Human Kinetics, 2023).
d. Discuss issues that might affect this individual’s ability to begin and adhere to
exercise training.
e. What considerations might affect decisions for exercise workload or intensity
progression?
f. Based on the subject’s medical history and test results, identify areas for which the
patient should be further educated (e.g., weight control, diet modification). Are there
other resources that you might use?
3
From J.K. Ehrman, P.M. Gordon, P.S. Visich, and S.J. Keteyian, Clinical Exercise Physiology HKPropel Access,
5th ed. (Champaign, IL: Human Kinetics, 2023).
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