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Transcript of Case
with coronary artery disease. Jack Palmer "Doc, the drugs aren't working for my chest pain!" Family History Current Medications Saja Almazrou coronary artery disease He is an avid golfer and prefers to walk the course, but this is becoming progressively more difficult for him due to frequent angina. He has had two coronary artery bypass operations in the past.A coronary angiogram performed 1 month ago revealed significant disease in the RCA proximal to his graft.but this was considered high risk for angioplasty. His dose of isosorbide mononitrate was increased at that time from 60 to 120 mg once daily. This had no effect on his angina. He is still using about 30 nitroglycerin tablets a week, and these do relieve his chest pain. He reports that most often the chest discomfort comes on with activity, such as walking up slight inclines on the golf course. The discomfort is located in the center of his chest and rated as a 3–4/10 on average. He reports that the chest discomfort slowly fades as he slows his activity. He also complains of occasional lightheadedness with a pulse around 50 bpm and SBP near 100 mm Hg. Ischemic cardiomyopathy Heart failure with an ejection fraction of 40% Dyslipidemia COPD (mild) Chronic low back pain Depression Acute anterior wall MI with CABG in 1976 Posterior lateral MI in 1990 and PTCA to the circumflex at that time Redo CABG in 1998 FH:Noncontributory for premature coronary artery disease SH:Retired dairy farmer, lives with wife, drinks occasionally, previous smoker—quit in 1998 twice daily once daily once daily once daily 325 mg once daily once daily once daily three times daily once daily once daily SL PRN All NKDA ROS No fever, chills, or night sweats. No recent viral illnesses. No shortness of breath; occasional cough with cold weather. No nausea, vomiting, diarrhea, constipation, melena, or hematochezia. No dysuria or hematuria. No myalgias or arthralgias. Physical Examination GEN Pleasant, cooperative man in no acute distress VS
BP 105/68, P 50, RR 22, T 36.4°C, Ht 5'11″, Wt 93 kg, waist circumference 43 in otherwise physical examination was normal. Labs Na 137 mEq/L
Hgb 11.8 g/dL Fasting lipid profile Chol 202 mg/dL
K 4.8 mEq/L
Cl 103 mEq/L
Plt 187 x 103/mm3
LDL 125 mg/dL
CO2 21 mEq/L
WBC 7.9 x 103/mm3
HDL 38 mg/dL
BUN 24 mg/dLMCV 77 m3
Trig 215 mg/dL
SCr 1.2 mg/dL MCHC 29 g/dL
Glu 98 mg/dL
Digoxin serum concentration: 1.8 ng/mL ECG Sinus rhythm, first-degree AVB, 50 bpm, old AWMI, no ST–T wave changes noted, QT/QTc 406/431 What drug-related problems appear to be present in this patient?
Could any of these problems potentially be caused or exacerbated by his current therapy? Case discussion Does this patient possess any modifiable risk factors for IHD? What pharmacotherapeutic options are available for treating this patient's IHD? Discuss the agents in each class with respect to their relative utility in his care. Given the patient information provided, construct a complete pharmacotherapeutic plan for optimizing management of his IHD. Mr Palmer improved hemodynamically following a switch from diltiazem to amlodipine. However, due to continued frequent episodes of angina, his amlodipine was titrated to 10 mg once daily. He returned to cardiology clinic today stating that his angina frequency has improved somewhat on the maximum dose of amlodipine but is still bothersome to him. His cardiologist decided to add ranolazine 500 mg twice daily to his regimen in an attempt to further decrease his angina frequency. What information will you communicate to the patient about his antianginal regimen to help him experience the greatest benefit and fewest adverse effects? What are the goals of pharmacotherapy for IHD in this case? What information will you communicate to the patient about his antianginal regimen to help him experience the greatest benefit and fewest adverse effects? What drug therapy changes would you recommend to avoid or minimize drug interactions with ranolazine? @salmazrou