CLINICAL PHARMACY CLERKSHIP

YEAR BACHELOR OF PHARMACY (HONOURS)

Faculty of Pharmacy
Universiti Kebangsaan Malaysia

TH

Clerkship Specialisation : Pharmacotherapy in Internal Medicine I

(Cardiovascular & Respiratory)
Date
: 2nd 4th May 2012
Case summary:
Unstable angina, atrial fibrillation

Name:
Khairul Fariza Binti Khairudin

A122581

PPUKM Preceptor : Miss Kong Sue Hong

FFar Preceptor
: Dr. Endang Kumolosasi
Marks:_________ /10

PATIENTS INFORMATION
Name: NCK
R/N: N256391
Date of admission: 29/04/2012

Age: 77
BW: 60 kg
Ht: 155 cm

MEDICAL HISTORIES
C/C: Presented with left sided chest pain
preceded with palpitation
FH:
Nil

PAST MEDICATION
HISTORY
1. T. Vastarel MR 35mg BD

Gender: Female
Race: Chinese
BMI: 25

HPI: Hypertension for the past 20 years,

paroxysmal atrial fibrillation on previous
admission (22/4/12)
SH:
Non-smoker
Non-alcoholic

PAST SURGICAL
HISTORY
Coronary Angiogram
(COROS) in 2009

2. S/L GTN PRN

3. T. Bisoprolol 7.5mg OD
4. T. Coversyl Plus 1/1 OD
5. T. Aspirin 75mg OD
6. T. Isordil 10mg TDS
7. T. Losec 20mg OD
8. Lovastatin 40mg ON
9. T. Warfarin 2mg weekdays
10. T. Warfarin 2.5mg weekend
ALLERGIES & INTOLERANCE
Drug or Environmental Allergens
No allergies

PAST MEDICAL HISTORY

1.Hypertension for 20 years
2.Dyslipidemia
3.Paroxysmal atrial fibrillation

Description of reaction
-

PCIs
-

MEDICATION ADHERENCE EVALUATION

Language skills
Understand Malay/Chinese
Senses
Hearing: Adequate
Vision: Adequate
Who looks after the treatment Care giver
LABORATORY INVESTIGATIONS
Parameter/Date
29/4
BP (mmHg)
121/50

30/4
124/56

1/5
107/53

2/5
122/55

HR (b/min)
64
56
53
60
RR (c/min)
22
24
24
o
Temp ( C)
37.2
37.4
36.4
Impression: The heart rate of this patient is slightly lower might be caused by the
Bisoprolol.
Endocrine
FBS
5.2
HbA1c (<6.5%)
5.6
Impression: The blood glucose level of this patient is normal.
FBC
WBC (4-11x109/L)
6.3
5.6
RBC (3.8-4.8x1012/L)
Hb (12.3-15.3 g/dL)
12.6
13.0
Hct (37-47%)
37.8
Platelet (150-400x109/L)
195
188
MCH (28-33 pg)
31.4
MCHC (15-45 g/dL)
33.5
MCV (76-95 fL)
Neutrofil (40-75%)
52
Lymphocyes(20-45%)
38.7
Monocytes(2-10%)
5.3
Eosinophil (1-4%)
3.5
Basophil (0-1%)
0.5
Impression: The full blood count results showed normal readings, indicating no
presence of infection.
LFT
ALT (0-31 u/L)
16
14
ALP (35-104 u/L)
60
59
T. Bili (0-17 umol/L)
7
14
Albumin (35-50 g/L)
40
42
T. Protein (66-87 g/L)
69
71
Impression: The liver enzymes level of this patient is normal, indicating normal liver
function.
RP & BUSE
SrCr (62-100 umol/L)
CLCr (mL/min)
Na+ (135-150 mmol/L)
K+ (3.5-5.0 mmol/L)
Urea (2.5-6.4 mmol/L)
Mg

82

67

84

62

137
3.3
8.6
0.67

139
3.8
6.1

137
4.0
9.8

139
3.7
9.2
0.75

Impression: The renal profile of this patient showed normal results.

Coagulation profile
INR
2.14
2.41
2.15
APTT (23-40 secs)
51.3
54.2
PT (11-16 secs)
22.6
24.7
CK
65
71
76
Trop T
<0.013
<0.013
0.016
Impression: The blood coagulation profile of this patient is higher than the normal
level/time because of the medications taken that can cause blood-thinning effect such
as Clopidogrel, Fondaparinux and Aspirin.
Lipid profile
T. Chol (<5.7 mmol/L)
5.00
LDL (<3.8 mmol/L)
3.04
HDL (>1.2 mmol/L)
1.30
TG (<1.4 mmol/L)
1.47
Impression: The triglycerides level of this patient is higher than the normal level and
is currently controlled with the Lovastatin. The LDL level is high because the
targeted LDL for angina patient is below 2.0 mmol/L.

No
.

Medication Name

Regimen

Date start

Indication

0.25mg in 100cc
over 30 minutes
(stat dose)

2/5

Treatment of atrial
fibrillation

Digoxin 0.5mg/2ml inj

(Lanoxin)

Bisoprolol Fumarate 2.5mg

tab (Concor)

1.25mg OD

2/5

Treatment of
hypertension

Clopidogrel 75mg tab

(Plavix)

75mg OD

1/5

Reduces rate of
atherothrombotic events
in patients with unstable
angina

Acetylsalicylic acid soluble

300mg (Aspirin-G)

150mg OD

30/4

Anticoagulant agent

2.5mg OD

30/4

Prevention of
complications of
unstable angina

Fondaparinux sodium
2.5mg/0.5ml prefilled syringe
(Arixtra)

Lovastatin 40mg tab

6

40mg ON

29/4

Treatment of
dyslipidemia

Omeprazole 20mg cap

(Losec-G)

20mg OD

30/4

Prophylaxis of stressinduced ulcer

Isosorbide dinitrate tab 10mg

(Isordil)

10mg TDS

30/4

Prevention and treatment

of angina pectoris

1 tab OD

30/4

Treatment of
hypertension

0.5mg PRN

2/5

Prophylaxis and
treatment of angina

10

Perindopril 4mg +
Indapamide 1.25mg tab
(Coversyl Plus)
Glyceryl trinitrate 0.5mg tab
(GTN)
Warfarin sodium 2mg tab

11
12

2mg OD
Trimetazidine MR 35mg tab
(Vastarel MR)

Anticoagulant agent

35mg BD

30/4

Prophylactic treatment of
episodes of angina
pectoris

DIAGNOSIS OR DIFFERENTIAL DIAGNOSIS

1. Atrial fibrillation
2. Unstable angina
CURRENT MEDICATIONS
No
Medication Name &
.
Regimen
1 Digoxin 0.5mg/2ml inj
(Lanoxin)
2 Bisoprolol Fumarate 2.5mg
tab (Concor)
3 Clopidogrel 75mg tab
(Plavix)
4 Acetylsalicylic acid soluble
300mg (Aspirin-G)
5 Fondaparinux sodium
2.5mg/0.5ml prefilled
syringe (Arixtra)

Route
29/4

30/4

Date
1/5

IV
Oral
/

/
(stat)
/

Oral
Oral
IV

/
(stat)

2/5
/

3/5

6
7
8
9

10
11
12

Lovastatin 40mg tab

Omeprazole 20mg cap
(Losec-G)
Isosorbide dinitrate tab
10mg (Isordil)
Perindopril 4mg +
Indapamide 1.25mg tab
(Coversyl Plus)
Glyceryl trinitrate 0.5mg
tab (GTN)
Warfarin sodium 2mg tab
Trimetazidine MR 35mg
tab (Vastarel MR)

SUMMARY OF PROGRESS
Date
Subjective
29/4 Underlying HPT,
dyslipidemia, mild to
moderate nonobstructive CAD, no
collapsing pulse, apex
beat non displaced, no
pedal edema.

30/4

Underlying HPT,
dyslipidemia, mild to
moderate nonobstructive CAD, no
collapsing pulse, apex
beat non displaced, no
pedal edema.

Oral
Oral

/
/

/
/

Oral

Oral

S/L
Oral
Oral

Objective
BP : 89/61
PR : 68
INR : 2.14

Assessment
Unstable angina
ECG shows
bradycardia,
ventricular
ectopic

Plan
-Start Fondaparinux
2.5mg
-cont. T. Vastarel
MR 35mg bd
-cont. S/L GTN prn
-cont. T. Bisoprolol
7.5mg od
-cont. T. Perindopril
4mg +Indapamide
1.25 mg
-cont. T. Isosorbite
Dinitrate 10mg tds
-cont. T. Omeprazole
20mg od
-cont. T. Lovastatin
40mg on
-T. Warfarin 2mg od
- ECG start if chest
pain.

BP : 100/57
PR : 54
T : 37
RR:20

Unstable angina

-Cont. Fondaparinux
and other medication
-withold Bisoprolol
-ECG start if chest
pain
-refer cardio for
angiogram

1/5

2/5

Chest pain,no sob, pain

at central of chest,
concious, alert.

BP: 146/86
PR : 109
T : afribile

ECG- AF no
obstructive
changes, unstable
angina, fast AF
but
hemodynamicall
y stable

-IV Digoxin 0.25

mcg
-start T. Bisoprolol
-to extend
Fondaparinux.
-to start warfarin.

Chest pain, palpitaiton,

unable to lie down,

BP :138/74
PR : 70
INR : 2.15

AF, unstable
angina,

-IV GTN infusion

stat 5mcg/kg/1Hr.
-withold Isosorbite
Dinitrate.
-cont. Fondaparinux
for 5 days.

MAJOR DIAGNOSIS
a. Pathophysiology/Pathogenesis of issue
Unstable angina is characterised by an imbalance between myocardial oxygen supply and
demand. The most common cause of UA is reduced myocardial perfusion that results from
coronary artery narrowing caused by a thrombus that developed on a disrupted
atherosclerotic plaque and is usually nonocclusive. Microembolisation of platelet aggregates
and components of the disrupted plaque causing distal microinfarction is believed to be
responsible for the release of myocardial markers in many of these patients.
A less common cause is dynamic obstruction, which may be caused by intense focal
spasm of a segment of an epicardial coronary artery (Prinzmetals angina). This spasm is
caused by hypercontractility of vascular smooth muscle and/or by endothelial dysfunction.
Dynamic coronary obstruction can also be caused by the abnormal constriction of smaller
vessels.
A third cause of UA is severe narrowing without spasm or thrombus. This occurs in some
patients with progressive atherosclerosis or with restenosis after a percutaneous coronary
intervention (PCI).
The fourth cause is arterial inflammation, caused by or related to infection, which may be
responsible for arterial narrowing, plaque destabilisation, rupture and thrombogenesis.
Activated macrophages and T-lymphocytes located at the shoulder of a plaque increase the
expression of enzymes such as metalloproteinases that may cause thinning and disruption of
the plaque, which in turn may lead to UA .

The fifth cause is UA secondary to a precipitating condition, which is extrinsic to the

coronary arterial bed. These patients have underlying coronary atherosclerotic narrowing that
limits myocardial perfusion, and they often have chronic stable angina.UA secondary to
precipitating conditions includes:

Increased myocardial oxygen requirements, such as fever,tachycardia and thyrotoxicosis

Reduced coronary blood flow such as hypotension
Reduced myocardial oxygen delivery, such as anaemia or hypoaemia.

b. Treatment goal
1. To immediate relief of chest pain due to angina attack ; this because sometimes the
patient chest pain do not resolve after taking single dose of S/L GTN and need extra dose
to resolve.
2. To prevent the recurrence of angina attack; the patient has AF and may cause heart failure
and MI.
3. Prevention of stroke and tachycardia-induced cardiomyopathy and amelioration of
symptoms; this because the patient have AF and may cause stroke and other symptoms
that present in the patient such as palpitation, chest discomfort, and shortness of breath.
c. Actual and recommended treatment
According to Clinical Practice Guidelines on UA/NSTEMI 2011, the goal of
management are to immediate relief of ongoing ischemia and angina, prevention of recurrent
ischemia, angina and serious adverse cardiac event. The first recommended medication is
oral antiplatelet agent such as acetylsalicyclic acid which is aldready given in this patient.
Next is Adenosine Diphosphate Receptor Agonist such as clopidogrel and ticlodipine. In this
patient clopidrogrel 75mg od is given and is appropriate. Anticoagulant also is recommended
in the guideline and in this patient, fondaparinux 2.5mg is given and is appropriate. Next
recommendation is anti-ischemic drug therepy which include nitrates and beta blocker. In
this patient, S/L GTN and isosorbide dinitrate is given while bisoprolol was withold in this
patient due to low heart rate that may be due to effect of bisoprolol. Since this patient not
suitable for taking beta blocker, calcium channel blocker such as verapamil or diltiazam can
be given as an alternative. Next is lipid modifying drugs is recommended as it have been
found to reduce major cardiac events such as atorvastatin and simvastatin, while this patient
had receive lovastatin. Lastly the recommended medication is ACE inhibitor for long term
prevention of recurrent ischemia and this patient has received perindopril.

d. Monitoring of treatment efficacy and safety

Drug
Fondaparinux sodium
2.5mg/0.5ml prefilled
syringe (Atrixtra)
OD, sc

Indications
Monitor CBC,
platelet count, stool
occult blood test, sign
and symptoms of
neurological
impairment
Antithrombolytic
agent. Act by
inhibiting adenosine
diphosphate pathway
of platelet thus
reduce platelet
aggregation.

Monitor efficacy
Controlled of blood
pressure to desired
target (130/80mmHg)

Acetylsalicylic acid
soluble 150mg od

Antithrombolytic
agent. Act by inhibit
synthesis of
thromboxane A2 thus
interfere platelet
aggregation.

Measure salicylate
concentration for
therapeutic effect is
about 30mg/dL.

Isosorbide dinitrate
10mg tds

Prevention of angina.
Nitrates is taken up
by vascular smooth
muscle, metabolized
to nitric oxide,
stimulate guanylate
cyclase, convert GTP
to cGMP, increase
cGMP activate
protein kinase G,
dephosphorylase

Blood pressure, heart

rate and frequency of
chest pain.

Tablet clopidogrel
75mg od

Monitor safety
Reduction in
frequency of angina
attack.
Prothombine time

Ex vivo test of
platelet aggregation,
electrocardiogram,
CT/MR scan to
diagnosis of stroke.

Monitor for sign of

bleeding, occult
blood testing. Side
effect of treatment:
gastrointestinal
discomfort (27%). As
clopidogrel is not
sensitive to PT, aPTT
and INR, thus
monitoring to these
parameter is not
essential. Monitor for
hematocrit,
hemoglobin and
platelet count is
necessary.
Sign of bleeding,
stool occult blood
test. Monitor for side
effect of
gastrointestinal
ulceration (6-31%).
APTT should be
monitored as aspirin
can affect time of
blood clot.
Monitor for side
effect of orthostatic
hypotension,
syncope, dizziness,
palpitations,
headache and blood
pressure should be
monitored to avoid
toxicity.
Stop nitrates
treatment if dry

Lovastatin 40mg
On

GTN 0.5mg

myosin light chains,

preventing interaction
of myosin and actin,
cause smooth muscle
relaxation.
Treatment for
hypercholesterolemia
.
Act by competitively
inhibiting HMG-CoA
reductase the enzyme
that catalyse the rate
limiting step in
cholesterol
biosynthesis.

Acute treatment of
angina. Nitrates is
taken up by vascular
smooth muscle,
metabolized to nitric
oxide, stimulate
guanylate cyclase,
convert GTP to
cGMP, increase
cGMP activate
protein kinase G,
dephosphorylase

mouth or blurred
vision developed.

Lipid profile
monitoring with
target LDL achieved.
Obtain lipid profile
for response at 4
weeks.

Relieve of chest pain,

heart rate and blood
pressure.

Monitor liver
function test before
initiating therapy, at 6
and 12 weeks after
initiation of therapy
or elevation of dose,
and 6 months
thereafter in patient
with history of
hepatic impairment of
patient clinically
indicated. Assess
creatinine kinase
levels when
symptomatic
myopathy occurs.
May consider
monitoring creatinine
kinase levels to
patient initiating
lovastatin therapy or
when dose increased.
Temporary
discontinue treatment
if myopathy
suspected or serum
transminase levels
exceed 3 times
normal level.
Monitor for side
effect of GTN:
headache, postural
hypotension, reflex
tarchycardia.
However the side
effect is lesser
because beta blocker
is given.

T. Trimetazidine MR
(Vasteral MR) 35mg
b.d.

T. Bisoprolol
Fumarate7.5mg od
Perindopril Erbumine
4mg and Indapamide
1.25mg
Digoxin

myosin light chains,

preventing interaction
of myosin and actin,
cause smooth muscle
relaxation.
Prophylactic
ST segment of
treatment of episodes depression, incident
of angina pectoris.
of angina attack
Adjuvant
symptomatic
treatment of vertigo
and tinnitus.
Adjuvant treatment of
the decline in visual
acuity and visual
field disturbances
presumably of
vascular origin.
Prevention of
recurrent ischemic
heart disease
symptoms
Treatment of
hypertension

BP, Heart rate and

ECG

Treatment of atrial
fibrillation

Serum digoxin level,

heart rate, ECG

Blood pressure

Monitor side effect of

TMZ :
Gastrointestinal
disorders,headaches,
vertigo, sleep
disorders,
aggravation of
Parkinsonian
symptoms,
Orthostatic
hypotension which
may contribute to
vertigo, fainting and
falling in elderly.
Blood pressure, ECG
Monitor patient BP
since patient have
low BP
BP, BUN, serum
creatine and
electrolytes.
Serum potassium
level, Serum digoxin
level, heart rate, ECG

PHARMACEUTICAL CARE ISSUES

No.

Description of
issue
Pain
management

Complication of issue

Management of issue

Monitoring of issue

Patient suffers from

chest pain due to
angina attack

Give opioid for mildto-moderate pain such

as tramadol or
dihydrocodeine

Drug
interaction
(Potential)

The synergistic effect

between Aspirin,
Fondaparinux and
Clopidogrel may
increase the risk of
bleeding

Stop Fondaparinux
after the completion
of regimen

Drug
The sublingual GTN
administration may not be
technique
administered correctly
because the angina
attack is not resolved
after 3 tablets

-Monitor the pain score

of patient
-Monitor the side
effects of opioid drug,
eg respiratory
depression
-Monitor patients
blood coagulation
profile
-Monitor the presence
of bleeding so that
appropriate treatment
can be given as soon as
possible
-Monitor the duration
of angina attack
-Monitor the
administration
technique

-Educate the patient

on the right way of
sublingual
administration
-Change the
sublingual tablet to
Nitrolingual pump
spray

REFERENCES
1. MIMS Malaysia
2. Lacy, C.F., Armstrong, L.L. et al. 2010-2011. Lexi-Comps Drug Information Handbook.
3.
4.
5.
6.
7.
8.

19th Edition.
WHO Pain Management Ladder
Clinical Practice Guidelines on the Management of UA and NSTEMI, June 2011.
Clinical Practice Guidelines on the Management of Hypertension, February 2008.
Clinical Practice Guidelines on the Management of Dyslipidemia
Braunwald, E. 1989. Unstable angina: A classification. Circulation 80: 410-414.
Prisant, L.M., von Dohlen, T., Rogers, W., Houghton, J.L., Carr, J.L. & Frank, M.J. 1992.
Pharmacotherapy of unstable angina. Journal of Clinical Pharmacy 32: 390-399.

9. Patterson, D.L. 1988. Management in unstable angina. Postgraduate Medical Journal 64:

271-277.