Case Presentation

CASE PRESENTATION
•Exertional Angina
•ACS(NSTEMI)
•Type I AV Block
•Hypertension
Presented by:
Sneha Susan George
IV PharmD
Reg No: 12Q0527
Patient Profile
Name : Basavachari IP/OP No :MH 00291760
Age : 70 DOA : 26-05-2016
Sex : Male DOD : 01-06-2016
Weight : 70 Kgs Department : Cardiology
Height : 155cm
Reasons for Admission
 c/o Exertional chest pain and mild breathlessness since 1 week
 Increased pain on day of admission
 Patient was normal a week back, but experienced chest pain –
compressing type of pain which increases on exertion
 Patient symptoms relieved with rest
 c/o Orthopnoea and palpitations
 c/o PND and Syncope
Past Medical History

 K/C/O HTN since 1 year
 But medication unknown
 No H/O IHD and DM and Epilepsy
Personal History
 Diet  Mixed
 Appetite  Normal
 Sleep  Disturbed
 Exercise  Brisk walking for 10
mins/day
 Alcohol  Non-Alcoholic
 Smoking  Chronic smoker years back,
but quit 5 years ago
General Physical Examination
Vital Signs :
 Temperature : Afebrile
 BP : 140/90 mm Hg Pulse : 76 bpm
Pallor Cyanosis Edema
- - +
 System Examination:
 CVS : S1, S2 (+)
 CNS : Normal
 RS : NVBS
Daily Reports
Day 1 : C/o Exertional Angina and dyspnoea
mild palpitations and breathlessness
 O/E
 CVS : S1, S2(+)
 BP : 140/90 mm Hg Pulse: 76 bpm
 Tests Advised
 CBC
 Serology
 ECG
 ECHO
 Urine tests
 Lipid profile
 Cardiac Biomarker
Daily Reports (Contd..)
 Advised Medication :
Drugs
Brand Generic Indication Dose Route Frequency
Name Name
T.Ecosprin Aspirin Antiplatelet 325mg PO 0–1–0
0–1–0
T.Clopilet Clopidogrel Antiplatelet 75mg PO
Lipid
T.Aztor Atorvastatin lowering 40mg PO 0–0–1
agent
T.Pan Pantoprzole PPI 40mg PO 1–0–0

 Other laboratory data:
Test Test Value Normal Value
CKMB 15.83 < 6.7 mg/L
Troponin T 1.076 < 0.1 mcg/L
Hb 11 13 – 17 g/dL
DC : N 82 55 – 80
L 50 25 – 40
Cholesterol 217.6 < 200 mg/dL
HDL 20.8 35 – 60
LDL 132.6 < 100 mg/dL
TG’s 160.5 < 150 mg /dL
Day 2 : c/o severe chest pain and breathlessness
 O/E :
 BP : 150/90 mm Hg Pulse : 80 bpm
Lab reports were obtained

 ECG indicated NSTEMI & Troponin T (+)
 12 lead ECG used
 PR interval - prolonged > 0.20 s
 QRS duration - < 0.12s
 P on T phenomenon present
 ST Segment normal
 ECHO Report - Type 1 AV Block
 Adequate LV Systolic function
 EF 54%
 Mild hypokinesia
 No clots
 C-X Ray – Enlarged Atrium
 Suggestions : plan PTCA/CAG – stenting to distal RCA
 Advised Medication :
 Continue medication and Add on :
Drugs
Brand Generic Indication Dose Route Frequency
Name Name
T.Pleotoz Cilostazol Antiplatelet 100mg PO 1-0-1
Integrillin Eptifibatide Antiplatelet 8 ml/hr IV
T.Restyl Alprazolam Anxiolytic 0.25mg PO 0-0-1

15 ml
Sy.Looz Lactulose Laxative PO 0-0-1
Inj. Heparin Anticoagulant 500 units IV Q4h

Electrolyte
IVF – NS 50 units IV
Replenisher
 I/O Ratio :
I : 2050 O : 1646 Balance : +404
Day 3 : Patient reviewed
c/o severe angina and breathlessness
 O/E :
 BP : 146/110 mmHg Pulse : 90 bpm
 Patient taken for CAG
 CAG Report:
 LMCA – Normal
 LAD – Type III Vessel; Minor plaquing in proximal and mid LAD
 LCX – Non dominant system with 20 – 30 % IL narrowing in proximal
LCX
 RCA – Dominant system with 20 – 30 % IL narrowing in proximal and
mid RCA
 Distal RCA – total occlusion with thrombus formation
 Final Impression : Single Vessel CAD
 Successful PTCA/Stenting to distal RCA
 I/O Ratio:
I – 1050 O – 975.5 Balance – 92.5
 Continue medication as advised

Day 4 : Patient reviewed
Patient better, symptoms were relieved
 O/E:
 BP: 132/80mmHg Pulse - 70bpm
 Medication continued
Day 5 : No fresh complaints

 O/E:
 Vitals found to be normal
 Patient advised discharge
Discharge Medication
Sl No. DRUG DOSE FREQUENCY
1 T.Ecosprin 150mg 0–1–0
2 T.Clopidogrel 75mg 0–1–0
3 T.Pan 40mg 1–0–0
4 T.Aztor 40mg 0–1–0
5 T.Pleotoz 100mg 1–0–1

Pharmaceutical Care Plan
SUBJECTIVE EVIDENCE OBJECTIVE EVIDENCE
 C/O exertional chest pain and mild  ECG-NSTEMI
breathlessness since 2 days  ECHO- Type I AV Block
 C/O dyspnoea & palpitations  EF-54%
 C/O orthopnoea & PND & syncope  Cardiac Biomarkers Elevated
 K/C/O HTN  Troponin T +ve
1.076(<0.1mcg/dL)
 CKMB- 15.83(<6.7mg/dL)
 CAG Report
 RCA: Total occlusion with
thrombus formation
 Lipid Profile Tests
 Cholestrol-217.6(<200mg/dL)
 HDL-20.8(35-60)
 LDL-182.6(<100mg/dL)
 TG’s-160.5(<150mg/dL)
 Hb-11%(13-17mg/dL)
 I/O ratio : 2050/1646=+404
1050/975.5=+92.5
Assessment
 Based on Subjective and Objective Evidence, Diagnosis was
confirmed as Exertional Angina, ACS-NSTEMI with Type I AV Block
and HTN.
Plan
 Short term goals
 To restore the blood supply in the area of infarction.
 To restore oxygen supply and maximize functional capacity of heart.
 To provide immediate pharmaceutical care and relieve the patient of
chest discomfort.
 To reduce blood pressure values.
 Long term goals:
 To prevent coronary artery re-occlusion.
 To prevent further complications of MI.
 To improve the patient’s quality of life.
Treatment Options
 Antiplatelet &Anticoagulant therapy : Inhibits platelet aggregation
 Aspirin – 150mg
 Clopidogrel -75mg
 Glycoprotein- IIb/IIIa Inhibitor :
 Abciximab
 Eptifibatide
 Tirofibian
 Heparin- anticoagulant. (prevents clotting)
 Heparin + triple antiplatelet therapy has superior functions in MI
 Anti Ischaemic Drugs
 Beta blockers
 Nitrates – ISDN
 Statins:
 Atorvastatin 40mg
Treatment Options(Contd..)
 Treatment of HTN with MI
• Beta blockers + Add on ACEI’s /ARB’s or Aldosterone
Antagonists
• Beta blockers – Antenolol – 25mg
• ACEI’s – Ramipril(2.5mg)
• ARB’s – Valsartan(80mg)
Monitoring Parameters
Disease Related :
 Monitor periodic lipid profile i.e. cholesterol to
prevent the further formation of plaque.
 Monitor the dietary intake of fats.
 Monitor the Cardiac Biomarkers i.e. CKMB &
Troponin levels .
 Monitor the BP and Heart Rate to avoid arrhythmias.
 Monitor ECG & ECHO.
Drug related:
 Monitor the ADR’s associated with the drugs.
 Monitor RFT and LFT
Problems Identified
Untreated Indication :
 Patient showed signs of edema
Hence diuretic must be prescribed.
Pantoprazole+Cilostazole- Increases toxicity of
cilostazole.
Aspirin+Cilostazole/Clopidogrel-Increases effects of
the other by synergism.
Goals Achieved
 Patient was relieved from signs and symptoms
 Successful CAG/PTCA – stenting done to distal RCA.
 The Cardiac Biomarkers were bought back to normal.
Patient Counseling
 Disease Related:
 Exertional Angina- Clinical syndrome of chest discomfort . Pain increases
on exertion/ physical activity.
 NSTEMI- ACS group of conditions that present with similar symptoms
of chest pain and NSTEMI is included in it. NSTEMI refers to Non ST
Elevated MI.
 AV block- Impairment in conduction between heart chambers that is atria
and ventricles of heart. Type I AV block- Not very severe. Do not
require treatment.
 Drug Related:
 Aspirin & Clopidogrel have ADR of GI bleeding. Hence must be taken
with or immediately after food.
 Pantoprazole tablets taken 30 mins before meals. Should NOT be
chewed. Do not bite. Swallow the tablet with water.
 Atorvastatins – Preferably taken during nights since cholesterol synthesis
occurs at that time. Statins inhibit it.
 Try to never miss a dose but if you skip a dose, DO NOT OVERDOSE.
Patient Counseling(Contd..)
 Lifestyle Modifications:
 Decrease the dietary intake of fat and consume foods rich in

antioxidants i.e. fruits and vegetables
 Maintain normal BMI
 Keep a check on body weight.
 Limit the alcohol intake
 Cessation of smoking helps lower the future risks
 Increase the aerobic physical activity.
 Adhere to the medications.
 Restrict the Na intake(<1.5g)
THANK YOU

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CASE PRESENTATION

Past Medical History

Pallor Cyanosis Edema

T.Ecosprin Aspirin Antiplatelet 325mg PO 0–1–0

T.Pan Pantoprzole PPI 40mg PO 1–0–0

Lab reports were obtained

Integrillin Eptifibatide Antiplatelet 8 ml/hr IV

T.Restyl Alprazolam Anxiolytic 0.25mg PO 0-0-1

Inj. Heparin Anticoagulant 500 units IV Q4h

 Continue medication as advised

Day 5 : No fresh complaints

1 T.Ecosprin 150mg 0–1–0

2 T.Clopidogrel 75mg 0–1–0

3 T.Pan 40mg 1–0–0

4 T.Aztor 40mg 0–1–0

5 T.Pleotoz 100mg 1–0–1

 Decrease the dietary intake of fat and consume foods rich in

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