Coronary Artery Disease and Heart Failure Case Study (Harding & Snyder Case Study 4): Nursing Clinical Reasoning Guide

How to use this guide: the textbook case and its questions are copyrighted, so they are not reproduced here. Instead, this guide explains the clinical content the case tests and walks through an original practice case with model answers. Use it to study and to check your reasoning, then answer the questions in your textbook in your own words. It is not an answer key.

Coronary artery disease and heart failure: what the case tests

Coronary artery disease (CAD) is the narrowing of the coronary arteries by atherosclerotic plaque. It reduces blood flow to the heart muscle, causing angina, and plaque rupture can cause a myocardial infarction (MI). Risk factors include hypertension, high LDL cholesterol, diabetes, smoking, obesity, physical inactivity, family history and age (Virani et al., 2023).

Heart failure (HF) is a syndrome in which the heart cannot pump enough blood to meet the body’s needs or can do so only at high filling pressures. CAD is a leading cause: an MI kills heart muscle, and the remaining muscle remodels and weakens (ischemic cardiomyopathy). HF is classified by ejection fraction: HF with reduced EF (HFrEF, EF 40% or less) and HF with preserved EF (HFpEF, EF 50% or more), with a mildly reduced category between (Heidenreich et al., 2022). The body compensates by activating the sympathetic nervous system and the renin-angiotensin-aldosterone system (RAAS), which retains sodium and water and constricts blood vessels. These responses help in the short term but worsen HF over time, and most HF medications block them.

Original practice case

Clinical reasoning questions and model answers

1. How are Mr. Price’s CAD and heart failure connected?

His MI destroyed part of the left ventricle. The surviving muscle stretched and remodeled, lowering his EF to 30%. A weak ventricle cannot handle extra volume, so when he took in more salt and stopped his diuretic, fluid built up quickly, first in the lungs (left-sided signs) and then in the body (right-sided signs). Ongoing CAD can also cause new ischemia that worsens HF, which is why troponin and an ECG are checked.

2. Which findings show left-sided and right-sided failure?

Left-sided: orthopnea, dyspnea on exertion, crackles, S₃, tachypnea and low SpO₂. Right-sided: jugular venous distension, 3+ pitting edema and rapid weight gain. He has both, which is common because left-sided failure eventually strains the right ventricle. A BNP of 1,620 pg/mL confirms ventricular stretch from volume overload.

3. What are the priority nursing interventions?

1. Position him in high Fowler’s position with legs dependent to reduce venous return and ease breathing.
2. Oxygen to keep SpO₂ at the ordered target; prepare for noninvasive ventilation if breathing worsens.
3. IV loop diuretic (for example, IV furosemide) as ordered. Expect diuresis within about 30–60 minutes.
4. Monitor response: hourly intake and output (an indwelling catheter is not routine), lung sounds, SpO₂, BP, HR and symptoms.
5. Daily weights at the same time, on the same scale, in similar clothing. Weight is the best measure of fluid change.
6. Electrolytes and kidney function: potassium, magnesium, sodium and creatinine at least daily during diuresis.
7. Cardiac monitoring for dysrhythmias, and activity limited to rest with gradual progression.

4. His potassium is 3.4 mEq/L. Why does this matter?

Loop diuretics cause potassium and magnesium loss. Hypokalemia increases the risk of dangerous dysrhythmias, especially in a damaged heart, and increases digoxin toxicity if the patient takes digoxin. The nurse should report the value, give potassium replacement as ordered, recheck levels and watch the ECG. Some HF medications, such as sacubitril/valsartan and mineralocorticoid receptor antagonists, raise potassium, so levels must be monitored in both directions.

5. What is guideline-directed medical therapy (GDMT) for HFrEF?

Four medication classes reduce death and hospitalization in HFrEF (Heidenreich et al., 2022):

Loop diuretics relieve congestion but do not improve survival. For his CAD, Mr. Price also needs high-intensity statin therapy, antiplatelet therapy as prescribed and risk factor control (Virani et al., 2023). Mr. Price is not yet on an MRA or an SGLT2 inhibitor, so the nurse can ask whether these will be added before discharge.

6. Mr. Price reports chest pressure during the night. What should the nurse do?

Treat this as possible ischemia. Stop activity, keep him in bed, check vital signs and SpO₂, obtain a 12-lead ECG as ordered or per protocol, and notify the provider. Give sublingual nitroglycerin as ordered if systolic BP is adequate and no phosphodiesterase-5 inhibitor has been taken recently; repeat assessment every 5 minutes. Draw troponin levels as ordered and call the rapid response team if pain continues or he becomes unstable.

7. Why was he readmitted, and what teaching prevents another episode?

The triggers were dietary sodium and skipping his diuretic, two of the most common and preventable causes of HF admissions. Teaching should include:

• Daily weights every morning, recorded in a log. Call the provider for a gain of about 2–3 lb in a day or 5 lb in a week, or as the provider directs.
• Sodium: read labels, limit processed and restaurant food, and follow the sodium goal his provider sets. Fluid restriction is individualized.
• Medications: take them every day. If diuretic timing is the problem, plan doses around outings instead of skipping them.
• Symptom zones: green (stable), yellow (weight gain, more swelling, more shortness of breath or needing more pillows: call the clinic) and red (shortness of breath at rest, chest pain, confusion: call 911).
• Activity: regular activity and a referral to cardiac rehabilitation.
• Other risks: blood pressure and diabetes control, no smoking, limit alcohol, flu and pneumococcal vaccines, and avoid NSAIDs, which cause sodium and water retention.
• Follow-up within 7 days after discharge.

Using teach-back and involving family improves adherence. See the nurse as health educator for teaching strategies.

Sample nursing care plan

Frequently asked questions

Related reading: cardiovascular assessment guide, subjective vs. objective nursing data and MCOs vs. ACOs (which explains why preventing readmissions matters to health systems).

Conclusion

CAD and heart failure cases ask nurses to trace symptoms back to a damaged heart and an overactive compensatory system, act quickly on congestion, monitor diuresis and electrolytes, support GDMT and teach self-care. Most readmissions, like Mr. Price’s, are triggered by salt, missed medications or unrecognized weight gain, which makes nursing education one of the most powerful treatments.

References

Harding, M. M., Kwong, J., Hagler, D., & Reinisch, C. (2023). Lewis’s medical-surgical nursing: Assessment and management of clinical problems (12th ed.). Elsevier.

Harding, M. M., & Snyder, J. S. (2019). Clinical reasoning cases in nursing (7th ed.). Elsevier Mosby.

Heidenreich, P. A., Bozkurt, B., Aguilar, D., Allen, L. A., Byun, J. J., Colvin, M. M., Deswal, A., Drazner, M. H., Dunlay, S. M., Evers, L. R., Fang, J. C., Fedson, S. E., Fonarow, G. C., Hayek, S. S., Hernandez, A. F., Khazanie, P., Kittleson, M. M., Lee, C. S., Link, M. S., … Yancy, C. W. (2022). 2022 AHA/ACC/HFSA guideline for the management of heart failure. Circulation, 145(18), e895–e1032. https://doi.org/10.1161/CIR.0000000000001063

Virani, S. S., Newby, L. K., Arnold, S. V., Bittner, V., Brewer, L. C., Demeter, S. H., Dixon, D. L., Fearon, W. F., Hess, B., Johnson, H. M., Kazi, D. S., Kolte, D., Kumbhani, D. J., LoFaso, J., Mahtta, D., Mark, D. B., Minissian, M., Navar, A. M., Patel, A. R., … Williams, M. S. (2023). 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA guideline for the management of patients with chronic coronary disease. Circulation, 148(9), e9–e119. https://doi.org/10.1161/CIR.0000000000001168