UArizona Global Campus Pharmacology Case Study Analysis And Response
Case Study
Chief complaint: “I’m here for a medication refill because I ran out of my medicines”.
HPI: Mrs. Allen is a 68-year-old African American who presents to the clinic for prescription refills. The patient indicates that she has noticed shortness of breath which started about 3 months ago. The SOB gets worse with exertion, especially when she is walking fast, and it is resolved when she is resting. She reports that she is also bothered by shortness of breath that wakes her up intermittently during her sleep. Her symptoms of shortness of breath resolve after sitting upright on 3 pillows. She also has lower leg edema pitting 1+ which started 2 weeks ago. She indicates that she often feels light headed at times with intermittent syncope episodes while going up a flight of stairs, but it resolves after sitting down to rest. She has not tried any over the counter medications at home.
She started taking her medications, but failed to refill the prescriptions because she cannot afford the medications as she only works part-time and lives alone. In addition, she reports that she does not think taking all these medications would help her condition anyway.
PMH: Primary Hypertension, Previous history of MI 1 year ago
Surgeries:
1 year ago-Left Anterior Descending (LAD) cardiac stent placement
Allergies: Penicillin
Vaccination History: Up-to-date
Social history:
High school graduate married and no children. Drinks one 4-ounce glass of red wine daily. She is a former smoker and stopped 5 years ago.
Family history:
Both parents are alive. Father has history of MI and valvular heart disease; mother alive and cardiac history is unknown. He has one brother who is alive and has history of MI 5 years ago at age 52.
ROS:
Constitutional: Lightheaded and faint with exertion. Respiratory: Shortness of breath with exertion. + Orthopnea. Cardiovascular: + 2 pitting leg edema for 3 weeks. Psychiatric: Non-contributory.
Physical examination:
Vital Signs: Height: 5 feet 1 inches Weight: 175 pounds BMI: 32, Obese, BP 160/92, T 98.0, P 111, R 22 and non-labored
HEENT: Normocephalic/Atraumatic, Bilateral cataracts; PERRLA, EOMI; Teeth intact. Negative for gum disease.
NECK: Neck supple, no palpable masses, no lymphadenopathy, no thyroid enlargement.
LUNGS: + Mild Crackles on inspiratory phase not clearing with cough. Equal breath sounds. Symmetrical respiration. No respiratory distress.
HEART: Normal S1 with S2 during expiration. An S4 is noted at the apex; + systolic murmur noted at the right upper sternal border without radiation to the carotids. Pulses are 2+ in upper extremities and 2+ in pedal pulses bilaterally. 2+ pitting edema to her knees noted bilaterally.
ABDOMEN: No abdominal distention. Nontender. Bowel sounds + x 4 quadrants. No organomegaly. Normal contour; No palpable masses.
GENITOURINARY: No CVA tenderness bilaterally. GU exam deferred.
MUSCULOSKELETAL: + Heberden's nodes at the DIP joints, hands. + Crepitus, bilateral knees. Slow gait but steady. No Kyphosis.
PSYCH: Normal affect. Cooperative.
SKIN: No rashes. Positive for dry skin.
Labs: Hgb 13.2, Hct 38%, K+ 4.0, Na+137, Cholesterol 228, Triglycerides 187, HDL 37, LDL 190, TSH 3.7, glucose 98.
A:
Primary Diagnosis: Congestive Heart Failure (CHF)
Secondary Diagnoses: Primary Hypertension, Obesity, Osteoarthritis (OA)
Differential Diagnosis: Peripheral Vascular Disease (PVD)
Plan:
Medications: Tylenol 650 mg PO Q4 hours as needed for arthritis pain
Labs: UA; Brain natriuretic peptide (BNP); LFTs and TSH; 12-lead EKG, Chest X-ray; Initial 2D echo with Doppler; Ankle-brachial index.
Additional lab results: Echo results 1 week ago: Left ventricular EJ Fraction decreased to 35 %
BNP – not available.
As a future FNP, you need to determine the medications for CHF/ASCVD. (Arteriosclerotic Cardiovascular Disease).
Questions:
1. According to the ACC/AHA guidelines, what medications should this patient be prescribed?
2. Does he need medication(s) given his history of MI?
3. Considering that you have a case study, you only need 2 posts for this discussion board, 1 initial and 1 reply. As usual, all posts must be supported by at least 2 peer reviewed references and all paragraphs must be cited.
Peer response 1:
The ACC/AHA guideline highlights different guidelines on the prevention of cardiovascular diseases. Referencing these guidelines the patient can be prescribed a range of medications such as HMG-CoA reductase inhibitors, acetylsalicylic acid, and regimes to lower her blood pressure. The patient can be prescribed aspirin but in low dose for approximately ten days and moderate statin therapies with drugs like Crestor (Rosuvastatin) and Lipitor (Atorvastatin) (Byrne et al., 2019). To reduce her high blood pressure level therapies such as long-acting ACE inhibitors or Angiotensin II receptor blockers (ARBs) should be included in her prescription. The practitioner should also look for other combinations such as calcium antagonist in her prescription. A combination of these medications would alleviate her suffering from atherosclerosis and control major hypertension/comorbidities that she is experiencing.
2.Allen’s previous history of myocardial infarction (MI) does not require her to have certain medications. Since there are already statin medications included during her prescription to control atherosclerosis would reduce risks associated with or occurrence of MI. Statins are prescribed to alleviate cholesterol plague and induces other pleiotropic effects, including the inhibition of inflammatory responses, antioxidant effects such as increased endothelial function (Bahiru et al., 2017). As such statin drugs like Lipitor and Crestor can prevent Mrs. Allen from the risks associated with myocardial infarction (MI) even though she had a history of MI.
References
Bahiru, E., de Cates, A. N., Farr, M. R., Jarvis, M. C., Palla, M., Rees, K., ... & Huffman, M. D. (2017). Fixed?dose combination therapy for the prevention of atherosclerotic cardiovascular diseases. Cochrane Database of Systematic Reviews, (3).
Byrne, P., Cullinan, J., Smith, A., & Smith, S. M. (2019). Statins for the primary prevention of cardiovascular disease: an overview of systematic reviews. BMJ open, 9(4), e023085.
Marchio, P., Guerra-Ojeda, S., Vila, J. M., Aldasoro, M., Victor, V. M., & Mauricio, M. D. (2019). Targeting early atherosclerosis: a focus on oxidative stress and inflammation. Oxidative medicine and cellular longevity, 2019.
https://www.cvpharmacology.com/vasodilator/renin
https://www.aafp.org/afp/2014/1001/afp20141001p503...
Peer response 2:
The guideline recommends various alternatives for patients with similar diagnoses as the one Mrs. Allen have. Arteriosclerotic cardiovascular disease, which is a thickening of arteries due to the buildup of plaque in their walls, that may restrict the blood flow to essential organs and may include medications like drugs for high cholesterol (Statins) and high blood pressure respectively; also, some lifestyles change like healthy diet alongside with a good exercise regimen may be need it for a safety treatment outcome. In this specific case, the health care professional needs to be aware of the patient's ejection function, which is decreased, and the severity of his symptomatology. Based on these, Mrs. Allen would be classified for the New York Heart Association (NYHA) to be class IV heart failure, which is the inability to carry on physical activity without distress and heart failure signs and indicating that the first treatment would need to include the angiotensin-converting enzyme inhibitors (ACEs). This first treatment is because studies such as the one conducted by (Herman et al.,2020) indicated that these drugs significantly reduce both the mortality and morbidity associated with CHF, especially in those who also present with left ventricular dysfunction the patient in this scenario. The advantage of the ACE inhibitors relies on the fact that they have a vasodilating effect that decreases left ventricular post load and reduces the process of ventricular remodeling.
Moreover, studies show that in progressive doses, they reduce mortality in the first 3-6 months of therapy, reduce hospitalization and relieve symptoms. For maximum effect, this therapy is recommended in combination with a beta-blocker in patients with an ejection fraction below 40%. There might be one limitation as ACE inhibitors tend to be less effective in African Americans due to their reduced level of renin (Helmer et al.,2018). Even so, until this is proven, the administration of beta-blockers together with ACE inhibitors and diuretics can be a suitable therapy for Mrs. Allen.
In terms of beta-blockers, the most suitable one for this patient would be Metoprolol because it is less expensive and is useful in decreasing the heart rate of the patient and high blood pressure, respectively. At a BP of 160/92, Mrs. Allen would be diagnosed with Stage II Hypertension, but due to the cardiac heart failure, she is considered a high-risk patient, which requires a drastic reduction of these values. (Morris,2020)
Nevertheless, the patient presents with shortness of breath and mild crackles, which can be the initial signs and symptoms of a possible respiratory decompensation. To reduce the risk of pulmonary edema, administration of a diuretic such as 12.5 mg of Hydrochlorothiazide can be useful. Despite all of these, it is essential to monitor Mrs. Allen's potassium levels to avoid further complications.
Additional Medication.
Due to her history of MI, the patient should receive aspirin to prevent eventual episodes as the guidelines recommend this drug, especially for those who were previously diagnosed with a STEMI. Even so, another risk factor that should be considered is her high cholesterol level (288) with low HDL and high LDL. In this scenario, the nurse practitioner should include 40 mg of Atorvastatin in the patient’s treatment plan to reduce these levels. Li et al. (2019) pointed out in their study that this drug's administration was more effective than the placebo in reducing the risk of cardiovascular complications, especially in patients who had a previous episode of MI.
References
Helmer A, Slater N, Smithgall S.(2018) A Review of ACE Inhibitors and ARBs in Black Patients With Hypertension. Ann Pharmacother. 2018 Nov;52(11):1143-1151. DOI: 10.1177/1060028018779082. Epub 2018 May 29. PMID: 29808707.
Herman LL, Padala SA, Annamaraju P, et al. (2020) Angiotensin-Converting Enzyme Inhibitors (ACEI)]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK431051/
Li, M., Wang, X., Li, X., Chen, H., Hu, Y., Zhang, X., Tang, X., Miao, Y., Tian, G., & Shang, H. (2019). Statins for the Primary Prevention of Coronary Heart Disease. BioMed research international, 2019, 4870350. https://doi.org/10.1155/2019/4870350