Rheuben Abragan

Reena Ross Vanguardia

Marvin Alamodin

Junley Troy Ceballos

Jerwin Joe Jumaoas-as

Hani Musa

CASE STUDY NUMBER 1

ISCHEMIC HEART DISEASE AND ACUTE CORONARY SYNDROME

PROBLEM IDENTIFICATION.

1.A. What drug related problems appear to be present in this patient?

- Aspirin and lisonopril. NSAIDS and ACE inhibitors must not be taken together as
it may cause less hypotensive effects and might cause injury if not taken with
strict and high precaution.

1.B.Could any of these problems potentially be caused or exacerbate by his

current therapt?

-could be since the patient is taking aspirin and lisonopril together, as well as
NSAIDS and ACE inhibitors.

DESIRED OUTCOMES

2. What are the goals of pharmacotherapy for IHD in this case?

-The prime goals of pharmacotherapy in ischaemic heart disease are easy to

define, but difficult to accomplish in practice. Relief of pain, breathlessness and
fatigue are the prime clinical targets for pharmacotherapy. In view of their sinister
significance, the electrophysiological indications of myocardial ischaemia, whether
symptomatic or silent, are also crucial targets towards which therapy must be
directed.

THERAPEUTIC ALTERNATIVES

3.A. Does this patient possess any modifiable risk factors for IHD?

-the patients’ modifiable risk factors are his weight and hypercholesterolemia. The
patients has calculated BMI of 27.7 making him overweight. Based on the
patients’ laboratory results, he has a borderline high cholesterol level, an elevated
LDL considering his CAD, a decreased HDL that increases the risk of CHD , an
elevated triglyceride. The patient is also known as an occasional drinker this may
exacerbate his conditions.

3.B. What pharmacotherapeutic options are available for treating this patients
IHD? Discuss the agent in each class with respect their relative usefulness in his
care?

The patient could receive one or more of the following : a nitrate, calcium channel
blocker, b adrenergic blocker, ranolazine.

- Nitrates are commonly used in the treatment of all angina syndromes.they

are effective in treating all forms of angina because they decrease venous
return to the heart and, therefore, decrease cardiac workload. Nitrates also
promote coronary vasodilation even in the presence of atherosclerosis.
Nitrates generally are well tolerated. To prevent loss of effect over time,
however, they must be scheduled to provide a nitrate-free interval of 10-12
hours, therefore, nitrates should be combined with a b-blocker or ccb.
The peripheral effects of sublingual NTG include dilation of both veins and
arteries. Venous dilation is more pronounced because relation of arterial
smooth muscle requires higher plasma NTG levels. By dilating the veins and
 reducing preload to the patient, filling pressures in the ventricles are
reduced. This, in turn, reduces myocardial oxygenated demand, thereby
relieving angina. The addition of long acting nitrates will provide an
additional protection against developing angina, and short acting NTG will
provide acute relief when an angina attack occurs.
- B-adrenergic blockers reduce myocardial oxygen demand by decreasing
cathecolamine- mediated increases heart rate, BP, and to some extent,
myocardial contractility. B-blockers have been demonstrated to be very
effective at reducing angina symptoms and ischaemia including silent
myocardial ischemia.
- Selective beta blockers is preferred to the patients condition because of his
history of COPD. A cardioselective beta blocker offers several advantages for
the patient. Drugs such as acebutolol, atenolol, and metoprolol primarily
inhibit b1 receptors in the heart and produce less blockade of b20 receptor
mediate airway responsiveness and blockade of b2-receptors can cause
severe bronchospasm and respiratory difficulty.
- Ccbs decrease myocardial oxygen demand and increase myocardial blood
supply. By inhibiting smooth muscle contraction, ccbs dilate blood vessels
and decrease resistance to blood flow. Dilation of peripheral vessels
reduces systemic vascular resistance and BP, thus decreasing the work load
of the heart. Coronary artery dilation improves coronary blood flow. The
agents primarily affect the resistance of peripheral and coronary arteriolar
smooth muscles. In the treatment of effort induced angina, ccbs reduce
myocardial oxygen consumption by decreasing vascular resistance, thereby
decreasing afterload. Their efficacy in vasosspastic angina is due to
relaxation of coronary arteries.
- Ranazoline inhibits the late phase of sodium current, improving the oxygen
supply and demand equation.inhibition of late Ina reduces intracellular
sodium and calcium overload, thereby improving diastolic function.
Ranazoline can be added to the therapeutic regimen of the patient since
isosorbide mononitrate did not help his angina after given to him.

OPTIMAL PLAN
 4. Given the patient information provided, construct a complete
pharmacotherapeutic plan for optimizing management of his IHD.

- sublingual nitroglycerin is to be given to induce immediate relief. A selective

eta blockers is given such as metoprolol or atenolol since the patient have a
history of COPD. A calcium channel blocker is also added to the
pharmacotherapy. Amlodipine is a good choice because it does not increase
mortality in patients with heart failure due to nonischemic left ventricular
systolic dysfunction and can be used safely in these patient unlike other ccbs.
Lastly ranazoline is recommended since according to the patient the isosorbide
mononitrate he was taking does not help relieve his angina.

OUTCOME EVALIATION.

5. When the patient returns to clinic for 2 weeks for a follow up visit, how will
you evaluate the response to his new anti angina regimen for efficacy and
adverse effect?

-let him know that these adverse effects are normal when you are taking up anti
angina regimen. Anti angina regimens has these side effects:

Headache

Flushing

Palpitations

Lethargy

Sleep disturbances

Dizziness

Constipation

Fatigue
Swelling in the feet, ankles, and legs

Low heart rate

Low BP

Not being able to perform sexually.

PATIENT EDUCATION

6. what information wil you communicate to the patient about his angina
regimen to help him experience the greatest benefit and fewest adverse effect?

-diet and nutrition

Controlling the amount of salt in the diet.less than 2000mg is relevant with
patients with advanced HF and fluid restriction of 1500-2000 ml should be advised
.
It should be also be advised that the salt substitutes must be used with caution as
they may contain potassium. In large quantities, in combination with an
angiotensin-converting enzyme inhibitor they may lead to hyperkalemia.
Alcohol consumption must be prohibited in suspected cases alcoholic
cardiomyopathy, but otherwise moderate alcohol intake.other nutritional advise
includes weigth reduction in the overweight or obese patients and prevention of
malnutrition and cardiac cachexia. Rest and exercise traditionally patients with HF
heve been instructed not to exercise in order to avoid deterioration. More
recently, physical rest is only advised in acute HF.