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Mrs. D., a 68-year-old divorced mother of three children and retired grocery store employee, presented to the emergency department with the sudden onset of indigestion, weakness, shortness of breath, and fatigue. The patient was a cigarette smoker with a history of hypertension that was poorly controlled, with intermittent adherence to prescribed medications. Upon examination, the patient was anxious, sweating, and breathing rapidly. Both her heart rate (86 beats/min) and blood pressure (178/112 mm Hg) were increased. Blood was drawn and revealed elevated levels of both troponin and creatine kinase. An electrocardiogram indicated ST segment elevation, and Mrs. D. was diagnosed with an acute ST segment elevation myocardial infarction (STEMI).

Mrs. D. was transported immediately to the cardiac catheterization laboratory, where virtually complete blockages were identified in two coronary arteries. The blockages were treated with balloon angioplasty followed by the placement of stents to keep the vessels open. The patient recovered well from the procedure and was discharged to her home on the third hospital day with prescriptions for aspirin, a diuretic, a beta-blocker, a statin, and an anticoagulant.

One week later, Mrs. D. was seen in follow-up by the cardiologist, who noted that the patient was regaining her strength and that her blood pressure, although still elevated (136/94 mm Hg), was under better control. However, Mrs. D. continued to smoke cigarettes, and the cardiologist encouraged her to participate in a smoking cessation program and to begin a regular exercise program. The cardiologist referred the patient back to her family physician for further follow-up.

Six weeks later, Mrs. D. was seen by her family physician, who noted that her mood was somewhat depressed and that she had not attempted to quit smoking nor start an exercise program. She complained about the number of medications that were prescribed by the cardiologist and admitted taking them only sporadically. Using a brief self-administered screening test for depression, Mrs. D. tested positive. She was encouraged to quit smoking, start exercising, and take her medications regularly. A referral also was made to a psychiatrist for evaluation and treatment of her depression.

Four weeks later, Mrs. D. was seen by a psychiatrist who conducted an interview and concluded that the patient had a major depressive disorder and started her on a selective serotonin reuptake inhibitor (SSRI) and began a course of cognitive behavioral therapy (CBT). Although there was some initial improvement in her depressive symptoms, Mrs. D. continued to have difficulty adhering to the prescribed medications and treatments. She continued to smoke and live an isolated and sedentary lifestyle.

Approximately 9 months after her percutaneous coronary intervention, Mrs. D. experienced an acute myocardial infarction (MI) at home, and attempts at resuscitation were unsuccessful.


It has been shown in many different settings that patients with coronary artery disease (CAD) have a comparatively high ...

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