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Thread: CC: "Chest heaviness/tightness at 10:15 hours"

  1. #1

    Default CC: "Chest heaviness/tightness at 10:15 hours"

    RR is a 65-year-old, 85-kg (187-lb) woman who developed chest heaviness/tightness at 10:15 hours while at her place of employment. Local paramedics were summoned and she was given three 0.4 mg sublingual nitroglycerin tablets by mouth, 325 mg ASA by mouth, and morphine 2-mg IV push without relief of chest discomfort. RR presented to the hospital at 11:00 hours. The hospital has a cardiac catheterization laboratory and primary PCI was selected as a treatment strategy for STE MI.

    PMH: Hypertension (HTN) for 18 years; dyslipidemia for 6 years; transient ischemic attack 2 years ago

    FH: Father with stroke at age 65; mother with HTN; no siblings

    SH: Smoked one pack per day for 30 years, quit 6 years ago

    Allergies: NKDA

    Meds: Amlodipine 10 mg by mouth once daily; enalapril 5 mg by mouth once daily; ASA 325 mg by mouth once daily; simvastatin 20 mg by mouth once daily at bedtime

    ROS: 10/10 chest discomfort/squeezing

    HEENT: Normocephalic atraumatic

    CV: Regular rate and rhythm S1, S2, -S3, -S4, no murmurs or rubs

    VS: BP 110/70 mm Hg; HR 98 ppm; T 37 C (98.6 F)

    Lungs: Clear to auscultation and percussion

    Abd: Nontender, nondistended

    GI: Normal bowel sounds

    GU: Stool guaiac negative

    Exts: No bruits, pulses 2+, femoral pulse present, good range of motion

    Neuro: Alert and oriented X 3, cranial nerves intact

    Labs: Sodium 138 mEq/L (138 mmol/L), potassium 4.2 mEq/L (4.2 mmol/L), chloride 105 mEq/L (105 mmol/L), bicarbonate 24 mEq/L (24 mmol/L), SCr 1.0 mg/dL (88 umol/L), glucose 95 mg/dL (5.3 mmol/L), WBC 9.9 x 10^3/mm3 (9.9 x 10^9/L), hemoglobin 15.7 g/dL (157 g/L), hematocrit 47%, platelets 220 x 10^3/mm3 (220 x 10^9/L), troponin I 1.8 ng/mL, oxygen saturation 99% on room air.

    ECG: Normal sinus rhythm, PR 0.16 seconds, ORS 0.08 seconds, QTc 0.38 seconds, occasional polymorphic premature ventricular contractions, 3 mm ST-segment elevation anterior lead

    CXR: No active disease

    Echo: Anterior wall dyskinesia, LVEF 45%
    Clinical Pharmacy Specialist - Infectious Diseases

  2. #2

    Default Re: CC: "Chest heaviness/tightness at 10:15 hours"

    Subjective
    1.Chest heaviness/tightness at 10:15 hours while at her place of employment
    2.Local paramedics were summoned and the patient was given three 0.4-mg sublingual nitroglycerin tablets by mouth, 325 mg ASA by mouth, and morphine 2-mg IV push without relief of chest discomfort.
    3.The patient present to the hospital at 11:00 hours.
    4.PMH of HTN for 18 years
    5.PMH of dyslipidemia for 6 years
    6.PMH of transient ischemic attack 2 years ago
    7.FH history of stroke (father at age 65) and HTN (mother); no siblings
    8.SH smoked one pack per day for 30 years, quit 6 years ago
    9.Amlodipine 10 mg PO qd
    10.Enalapril 5 mg PO qd
    11.ASA 325 mg PO qd
    12.Simvastatin 20 mg PO qd at bedtime

    Objective
    1.Troponin I 1.8 ng/mL
    2.ECG: Normal sinus rhythm, PR 0.16 seconds, ORS 0.08 seconds, QTc 0.38 seconds, occasional polymorphic premature ventricular contractions, 3 mm ST-segment elevation anterior lead
    Last edited by Janis.Y.Chen; Sat 4th June '16 at 2:30pm.
    Clinical Pharmacy Specialist - Infectious Diseases

  3. #3

    Default Re: CC: "Chest heaviness/tightness at 10:15 hours"

    Group related data

    Chest pain group
    Chest heaviness/tightness at 10:15 hours while at her place of employment
    Local paramedics were summoned and the patient was given three 0.4-mg sublingual nitroglycerin tablets by mouth, 325 mg ASA by mouth, and morphine 2-mg IV push without relief of chest discomfort.
    The patient present to the hospital at 11:00 hours.
    SH smoked one pack per day for 30 years, quit 6 years ago
    Troponin I 1.8 ng/mL
    ECG: occasional polymorphic premature ventricular contractions, 3 mm ST-segment elevation anterior lead

    HTN group
    PMH of HTN for 18 years

    Meds of amlodipine 10 mg PO qd, enalapril 5 mg PO qd
    + FH for HTN (mother)

    Dsylipidemia group
    PMH of dyslipidemia for 6 years
    Simvastatin 20 mg PO qd at bedtime

    Transient ischemic attack group
    PMH of transient ischemic attack 2 years ago
    ASA 325 mg PO qd
    + FH history for stroke (father at age 65)
    Last edited by Janis.Y.Chen; Sat 4th June '16 at 2:46pm.
    Clinical Pharmacy Specialist - Infectious Diseases

  4. #4

    Default Re: CC: "Chest heaviness/tightness at 10:15 hours"

    Determine each problem

    • STE MI
    • HTN
    • Dyslipidemia
    • Transient ischemic attack
    Clinical Pharmacy Specialist - Infectious Diseases

  5. #5

    Default Re: CC: "Chest heaviness/tightness at 10:15 hours"

    Access each problemSTE MI
    • Acuity (acute or chronic)
    • Severity (mild, moderate, or severe)
    • Symptom level (symptomatic or asymptomatic)
    • Treatment status (treated or untreated)
    • Degree of control (controlled or uncontrolled)
    • Classification (staging of disease)
    Clinical Pharmacy Specialist - Infectious Diseases

  6. #6

    Default Re: CC: "Chest heaviness/tightness at 10:15 hours"

    Access each problem

    STE MI

    • Acuity (acute)
    • Severity (TIMI score 4 points, 30-day mortality: 7.3%; severe)
    • Symptom level (symptomatic)
    • Treatment status (treated)
    • Degree of control (uncontrolled)
    • Classification (null)


    HTN

    • Acuity (chronic)
    • Severity (unknown)
    • Symptom level (asymptomatic)
    • Treatment status (treated)
    • Degree of control (controlled)
    • Classification (unknown)


    Dyslipidemia

    • Acuity (chronic)
    • Severity (unknown)
    • Symptom level (asymptomatic)
    • Treatment status (treated)
    • Degree of control (unknown)
    • Classification (unknown)


    Transient ischemic attack

    • Acuity (chronic)
    • Severity (unknown)
    • Symptom level (symptomatic)
    • Treatment status (treated)
    • Degree of control (controlled)
    • Classification (unknown)
    Clinical Pharmacy Specialist - Infectious Diseases

  7. #7

    Default Re: CC: "Chest heaviness/tightness at 10:15 hours"

    Identify the active problems

    • STE MI
    • HTN
    • Dyslipidemia
    • Transient ischemic attack
    Last edited by Janis.Y.Chen; Sat 4th June '16 at 3:50pm.
    Clinical Pharmacy Specialist - Infectious Diseases

  8. #8

    Default Re: CC: "Chest heaviness/tightness at 10:15 hours"

    Identify the inactive problems
    • Null
    Last edited by Janis.Y.Chen; Sat 4th June '16 at 3:49pm.
    Clinical Pharmacy Specialist - Infectious Diseases

  9. #9

    Default Re: CC: "Chest heaviness/tightness at 10:15 hours"

    Rank the problems

    Active problems that need immediate therapeutic intervention
    • STE MI


    Active problems requiring less immediate therapeutic intervention
    • HTN
    • Dyslipidemia
    • Transient ischemic attack


    Inactive problems of historical interest
    • Null


    The patient's prioritized patient problem list is as follows:
    1.STE MI
    2.HTN
    3.Dyslipidemia
    4.Transient ischemic attack
    Last edited by Janis.Y.Chen; Sat 4th June '16 at 3:48pm.
    Clinical Pharmacy Specialist - Infectious Diseases

  10. #10

    Default Re: CC: "Chest heaviness/tightness at 10:15 hours"

    Step 1 - Determine short-term and long-term goals of therapy
    Problem No.1: STE MI

    • Short-term goal: a.early restoration of blood flow to the infarct-related artery to prevent infarct expansion; b.prevention of death an other MI complications; c.prevention of coronary artery reocclusion; and as evidence of restoration of coronary artery blood flow; d.relief of ischemic chest discomfort; and e.resolution of ST-segment and T wave changes on the ECG.
    • Long-term goal: control of cardiovascular risk factors, prevent of additional CV events, including reinfarction, stroke, and HF, and improvement in quality of life.

    Problem No.2: HTN
    Short-term goal: target a specific BP goal, in this patient <140/90 mm Hg
    Long-term goal: reduce the risk of CVD and target organ damage
    Problem No.3: Dyslipidemia
    Short-term goal: LDL target according to the Framingham Point Scale for estimating 10-year CHDrisk
    Long-term goal: reduce the risk of CVD
    Problem No.4: Transient ischemic attack
    Short-term goal: Reducing secondary brain damage by reestablishing and maintain adequate perfusion to marginally ischemic areas of the brain and protecting these areas from the effects of ischemia
    Long-term goal: Prevention of a recurrent stroke through reduction and modification of risk factors and by use of appropriate treatments

    Step 2 - Create a List of Options
    Problem No.1: STE MI
    • Nonpharmacologic therapy
      • Primary PCI

    • Early pharmacologic therapy
      • Fibrinolytic therapy
        • Systemic, nonfibrin-specific (streptokinase)
        • Systemic, fibrin-specific (alteplase, reteplase, tenecteplase)

      • Antiplatelets
        • Systemic, NSAIDs, ASA
        • Systemic, platelet P2Y12 inhibitor, hepatic prodrug (clopidogrel, tricagrelor)
        • Systemic, platelet P2Y12 inhibitor, intestinal prodrug (prasugrel)
        • Systemic, GP IIb/IIIa receptor inhibitor (abciximab, eptifibatide, tirofiban)

      • Anticoagulants
        • Systemic, heparin (unfractionated heparin)
        • Systemic, LMWH (enoxaparin)
        • Systemic, thrombin inhibitor (bivalirudin)
        • Systemic, FXa inhibitor (fondaparinux)

      • Nitrates
        • Systemic (nitroglycerin)
        • Sublingual (nitroglycerin)

      • beta-Blcokers
        • Systemic, beta1 receptor-selective (metoprolol, atenolol)
        • Systemic, non-selective (propranolol)

      • Calcium channel blockers
        • Systemic, nondihydropyridine (diltiazem, verapamil)
        • Systemic, dihydropyridine (amlodipine)

      • Analgestics
        • Systemic, opiates (morphine)

    • Secondary prevention following MI
      • Antiplatelets
        • Systemic, NSAIDs, ASA
        • Systemic, platelet P2Y12 inhibitor, hepatic prodrug (clopidogrel, tricagrelor)
        • Systemic, platelet P2Y12 inhibitor, intestinal prodrug (prasugrel)

      • beta-Blcokers
        • Systemic, beta1 receptor-selective (metoprolol, atenolol)
        • Systemic, non-selective (propranolol)

      • Nitrates
        • Systemic (nitroglycerin)

      • Calcium channel blockers
        • Systemic, nondihydropyridine (diltiazem, verapamil)
        • Systemic, dihydropyridine (amlodipine)

      • ACE inhibitors
        • Systemic, prodrug (enalapril, ramipril, trandolapril)
        • Systemic, non-prodrug (captopril, lisinopril)

      • ARBs
        • Systemic, AT1 receptor-selective (candesartan, valsartan, losartan)

      • Aldosterone antagonists
        • Systemic (eplerenone, spironolactone)

      • Lipid-lowering agents
        • Systemic, statins (atorvastatin, fluvastatin, lovastatin, pitavastatin, pravastatin, rosuvastatin, simvastatin, )
        • Systemic, bile acid sequestrants (cholestyramine, colesevelam, colestipol)
        • Systemic, cholesterol absorption inhibitor (ezetimibe)
        • Systemic, nicotinic acid (niacin)
        • Systemic, fibric acid derivatives (fenofibrate, gemfibrozil)
        • Systemic, omega-3-fatty acids (lovaza)

    Problem No.2: HTN

    • Nonpharmacologic treatment
      • Weight reduction in overweight or obese individuals
      • Adoption of a diet rich in potassium and calcium
      • Dietary sodium restriction
      • Physical activity
      • Moderation of a alcohol consumption

    • Pharmacologic treatment
      • Diuretics
        • Thiazides (chlorthalidone, indapamide, hydrochlorothiazide, metolazone)
        • Loops (bumetanide, furosemide, torsemide)
        • Potassium-sparing (amiloride, triameterene)

      • Aldosterone antagonists (spironolactone, eplerenone)
      • beta-Blcokers
        • beta1-selective (atenolol, bisoprolol, metoprolol)
        • non-selective (nadolol, nebivolol, propranolol, timolol)
        • Mixed alpha- and beta-blockers (carvedilol, labetalol)

      • CCBs
        • Nondihydropyridine (diltiazem, verapamil)
        • Dihydropyridine (amlodipine, felodipine, isradipine SR, nicardipine SR, nifedipine XL, nisoldipine)

      • ACE inhibitors
        • Prodrug (benazepril, enalapril, fosinopril, moexipril, perindopril, quinapril, ramipril, trandolapril)
        • Non-prodrug (captopril, lisinopril)

      • ARBs (candesartan, eprosartan, irbesartan, losartan, olmesartan, telmisartan, valsartan)
      • Renin inhibitors (aliskiren)
      • alpha-Blockers (doxazocin, terazosin, prazosin)
      • Central alpha2-agonists (clonidine, methyldopa, guanfacine, guanabenz)

    Problem No.3: Dyslipidemia

    • Nonpharmacologic treatment
      • Therapeutic lifestyle change/TLC
        • LDL-raising nutrients restriction
          • Saturated fats restriction
          • Dietary cholesterol resstriction

        • LDL-lowering plant stannous/sterols
        • Increased viscous (soluble) fiber
        • Total calories balance to maintain desirable body weight
        • Physical activity

    • Pharmacological treatment
      • Statins (atorvastatin, fluvastatin, lovastatin, pitavastatin, pravastatin, rosuvastatin, simvastatin)
      • Bile acid sequestrants (cholestyramine, colesevelam, colestipol)
      • Cholesterol absorption inhibitor (ezetimibe)
      • Nicotinic acid (niacin)
      • Fibric acid derivatives (fenofibrate, gemfibrozil)
      • Omega-3-fatty acids (lovaza)

    Problem No.4: Transient ischemic attack

    • Secondary prevention
      • Nonpharmacologic therapy
        • Carotid endarterectomy
        • Carotid angioplasty

      • Pharmacologic therapy
        • Antiplatelet agents
          • NSAIDs (ASA)
          • P2Y12 receptor inhibitors, non-prodrug (ticlopidine)
          • P2Y12 receptor inhibitors, prodrug (clopidogrel)
          • TXA2 inhibitors (ER dipyridamole)

        • Anticoagulation
          • Nonspecific (warfarin, apart from bivalirudin)

    Step 3 - Eliminate Options Based on Patient-Specific and External Factors
    Problem No.1: STE MI
    Reperfusion therapy for patients with STE MI any regional medical system must seek to enable rapid recognition and timely reperfusion. If primary PCI is chosen as the approach of reperfusion it should begin within 90 minutes or less in PCI-capable hospital. If the patient arrives in a non-PCI-capable hospital and is to be transferred to a PCI-capable hospital, the FMC should be within 120 minutes o less. Therefore for this patient the selection of reperfusion is depending on FMC-to-device time.

    Now we assume that this hospital is a PCI-capable hospital. So this patients should undergoes PCI. Therefore we eliminate fibrinolytic therapy. Together with PCI the guideline recommend antithromotic and anticoagulant therapy to support primary PCI. Because this patient has history of prior TIA so we eliminate the option of prasugrel. Because of the risk of catheter thrombosis we eliminate the option of fondaparinux.
    Elimination:
    • Fibrinolytic therapy
    • Prasugrel
    • Fondaparinux

    Current guideline recommends both UFH and bivalirudin as the choice of anticoagulant therapy to support primary PCI. But the evidence for UFH is level C and for bivalirudin is level B so we choose the later. Therefore eliminate UFH. Bivalirudin may increase the risk of bleeding together with warfarin which is indicated for secondary TIA prevention.
    Eliminate:

    • UFH
    • LMWH

    Although nitroglycerin can ameliorate symptoms and signs of myocardial ischemia by reducing LV preload and increasing coronary blood flow, it generally does not attenuate the myocardial injury associated with epicardial coronary artery occlusion unless vasospasm plays a significant role. Besides, the patient did not respond to three doses of sublingual NTG. Therefore we eliminate IV and SB NTG.
    Elimination:
    • IV NTG
    • SB NTG

    The guideline does not support the use of CCBs: an overview of 28 RCTs involving 19,000 patients demonstrated no beneficial effect on infarct size or the rate of reinfarction when calcium channel blocker therapy was initiated during either the acute or convalescent phase of STE MI. But in our patient the amlodipine has effectively managed the patient's HTN. So we don't eliminate the amlodipine.

    Morphine was used but the patient's symptoms did not relieve. Therefore we eliminate morphine.
    Eliminate:
    • Morphine

    The guideline recommends an aldosterone antagonist to patients with STE MI who are already receiving an ACE inhibitor and beta blocker and who have an EF less than or equal to 0.40. This patient has a LVEF of 45%, so we eliminate aldosterone antagonist.
    Elimination:
    • Aldosterone antagonist

    Problem No.2: HTN
    The JNC 8 guideline recommended four types of anti-HTN drugs as the first-class choice to treat HTN, including: thiazide-type diuretics, CCBs, ACE inhibitors, and ARBs. Although this patient's BP is under good control with amlodipine and enalapril, this patient has compelling indication and according to JNC7 the preferred anti-HTN agent should be a thiazide-type diuretic agent with or without an ACE inhibitor. Therefore we eliminate CCBs, aldosterone antagonists, ARBs, renin inhibitors, alpha-blockers, central alpha2-agonists. beta-Blockers cannot be eliminated because of other medical problems (STE MI).
    Elminiante:
    • CCBs
    • aldosterone antagonists
    • ARBs
    • Renin inhibitors
    • alpha-Blockers
    • Central alpha2-agonists

    Problem No.3: Dyslipidemia
    This patient is taking simvastatin but we don't know how well her lipid profile is controlled. In the guideline the panel found the nonstatin therapy, as compared with statin therapy, did not provide acceptable ASCVD risk-reduction benefits relative to their potential for adverse effects in the routine prevention of ASCVD. Therefore we eliminate non-statin lipid lowering agents.
    Eliminate:
    • Bile acid sequestrants
    • Cholesterol absorption inhibitors
    • Nicotinic acid
    • Fabric acid derivatives
    • Omega-3-fatty acids

    Problem No.4: Transient ischemic attack
    The current guideline of TIA recommends CEA (carotid endarterectomy) for patients with a TIA within the past 6 months and ipsilateral severe (70%-99%) carotid artery stenosis as documented by noninvasive image if the perioperative morbidity and mortality risk is estimated to be <6%; for patients with recent TIA and ipsilateral moderate (50%-69%) carotid stenosis as documented by catheter-based imaging or noninvasive imaging with corroboration. Therefore for our patient the CEA should be eliminated.
    Eliminate:
    • CEA

    The current guideline recommends CAS (carotid angioplasty) as an alternative to CEA for symptomatic patients at average or low risk of complications associated with endovascular intervention when the diameter of the lumen of the ICA (internal carotid artery) is reduced by >70% by noninvasive imaging or >50% by catheter-based imaging or noninvasive imaging with corroboration and the anticipated rate of periprocedural stroke or death is <6%. Because our patient has a history of prior TIA two year ago we eliminate the option of CAS.
    Eliminate:
    • CAS

    Current guideline recommends the use of antiplatelet agents rather than oral anticoagulation to reduce the risk of recurrent stroke and other cardiovascular events. However, this patient has another medical problem (STE MI) and so we cannot eliminate oral anticoagulation. However, warfarin is not recommended so we eliminate warfarin.

    Current guideline notes that the combination of aspirin and clopidogrel, when initiated days to years after a TIA and continued for 2 to 3 years, increases the risk of hemorrhage relative to either agent alone and is not recommended for routine long-term secondary prevention after TIA. But we cannot eliminate the P2Y12 inhibitor except prasugrel.
    Eliminate:
    • Prasugrel

    Current guideline recommend VKA therapy (target INR, 2.5; range 2.0-3.0) for 3 months in most patients with TIA in the setting of acute MI with or without LV mural thrombus formation. Therefore the warfarin should not be eliminated. But this patient already use bivalirudin to combine with primary PCI to treat STE MI. So the warfarin and bivalirudin should be separated with each other to make sure the risk of bleeding is under control. Therefore in the pharmacodynamics duration of bivalirudin warfarin should not be given to the patient.
    Step 4 - Select Appropriate Drug and NonDrug Interventions
    Problem No.1: STE MI
    Rx:

    • Primary PCI
    • ASA tablet 325 mg PO before procedure, then maintenance with 81 mg PO qDay indefinitely
      Clopidogrel tablet 600 mg PO before primary PCI, then maintenance with 75 mg qDay for 1 year
    • Abciximab injectable solution 21.25 mg IV over at least 1 min 10-60 min before the start of primary PCI, then 10 mg/min IV continuous infusion for 12 hr
    • Bivalirudin powder for injection 63.75 mg IV bolus initially, then 148.75 mg/hr for the duration of procedure
    • Metoprolol tablet 50 mg PO q6hr for 48 hours initially; then 100 mg PO q12hr indefinitely
    • Enalapril tablet 5 mg PO qDay indefinitely

    Problem No.2: HTN
    The anti-HTN regimen is a thiazide diuretic agent with or without an ACE inhibitor for this patient according to current evidence. There are four thiazide diuretics, including chlorthalidone, indapamide, hydrochlorothiazide, and metolazone.

    First, chlorthalidone has a oral bioavailability of 65%. Therefore many predictable and unpredictable factors that alter oral drug absorption process can affect this drug's effect, although we can avoid them via patient education. Second, chlorthalidone has a very long half-life (40-60 hr if renal function is normal). Although the long half-life makes once-per-day regimen for chlorthalidone possible which may improve the patient adherence, attention must be paid that the drug has a prolonged adverse effects in the presence of overdose or other settings when ADR happens. Also, modification of drug dosage regimen might take 8 to 13 days (i.e., 25 mg Qday) to reach new steady, which is too long to make the appropriate quick re-evaulation of drug regimen.

    Indapamide has a high potency (2.5 mg PO qDay), a higher oral bioavailability (93%). If the effect-dose curve is too steep, a little change in the plasma drug concentration due to bioavailabliltiy would result in large change in drug effect and toxicity.



    Chlorthalidone tablet 25 mg PO Qd indefinitely
    Enalapril tablet 5 mg PO qDay indefinitely
    Last edited by admin; Thu 30th June '16 at 11:27pm.
    Clinical Pharmacy Specialist - Infectious Diseases

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