Case Presentation of IHD

Hetal Gosai
Pharm. D 4th year
INTRODUCTION
Also called coronary artery disease(CAD)
It is a condition where there is an in adequate
supply of blood and oxygen to a portion of
myocardium.
Imbalance between myocardial oxygen
supply and demand.
Caused mainly by atherosclerosis of coronary
artery
• It includes
– Angina : stable, unstable and prinzmetal
– Myocardial infarction
– Heart failure and arrhytmia
Atherosclerosis
• Progressive inflammatory disorder of the arterial
wall characterised by focal lipid rich deposits of
atheroma
• Remain clinically assymptomatic until
– large enough to impair tissue perfusion,
– Ulceration and disruption of the lesion result in
• thrombotic occlusion
– Distal embolisation of the vessel.
• Clinical manifestations depend upon the site of the
lesion and the vulnerability of the organ supplied.
 Risk factor of Atherosclerosis
• Effect of risk factors is multiplicative rather than additive.
• It is important to distinguish between relative risk and absolute risk.
• Absolute Risk
– Age • Relative Risk
– Smoking
– Male sex
– Hypertension
– Positive family history
– Diabetes mellitus
– Haemostatic factors.
– Physical activity
– Obesity
– Alcohol
– Other dietary factors
– Personality
– Social deprivation
Myocardial infarction
• Evidence of myocardial necrosis in a clinical
setting consistent with myocardial ischaemia,
in which case any one of the following meets
the diagnosis for MI:
– Detection of rise and/or fall of cardiac
biomarkers (preferably troponin),
– ECG changes indicative of new ischaemia (new
ST-T changes or new left bundle branch block)
– Development of pathological Q waves
– Imaging evidence of new loss of viable myocardium
or new regional wall motion abnormality
Diagnosis
• ECG
A Normal ECG complex.
B Acute ST elevation (‘the current of
injury’).
C Progressive loss of the R wave,
developing Q wave, resolution of the
ST elevation and terminal T wave
inversion.
D Deep Q wave and T- wave
inversion.
E Old or established infarct pattern
NSTEMI
• ECG
Epidemiology
• Deaths due to cardiovascular diseases in
India increased from 1.3 million in 1990
to 2.8 million in 2016, and more than half
the deaths caused by heart ailments in
2016 were in persons less than 70 years
of age.
CASE PRESENTATION
SUBJECTIVE DATA
• Age: 84 years
• Gender: female
• Date of admission:5/10/19
• Date of discharge:18/10/19
• Complaints on admission:
– Vomiting containing food particles X 3 days
– Anasarca; pedal edema periorbital puffiness X 7 days
– Abdominal pain X 3 days; para-umbilical
– Decreased UOP X 1 day
– Breathlessness on rest X 15 days
• Medical history:
– K/C/O IHD since X 10 months
– H/O an ischemic thrombus before 10 months
• Medication history:
– Atorvastatin 40mg 0-0-1
– Aspirin 150 mg 0-1-0
– Amlodipine 5 mg 1-0-0
• Patient has no social and family history
PROVISIONAL DIAGNOSIS
• Kidney related?
• Heart disease?
OBJECTIVE DATA
• Temperature : normal
• Blood pressure : 150/90 mm Hg
• Pulse rate: 110 bpm
• spO2: 97% on RA
• RBS: 56 mg/dl (was given inj. Dextrose 25% 1 pint iv 8 hourly)
• RS: air entry + bilateral ISA crepts
• GIT: P/A soft NT
• CNS: concious and oriented
 LABORATORY DATA
5/10 9/10 18/10

Hb 9.30 8.80 9.30 12-17.5 gldl

• Breathlessness
RBC - 3.04 - 4.2-6.1

• Anasarca13,400
WBC 6400 9000 4500-11000
cells/cmm
• Abdominal
neutrophils 78 pain 67 69 40-80%

• Vomiting 20
Lymphocytes 31 29 20-80%

Monocytes 1 1 1 1-20%

eosinophils 1 1 1 1-6%

platelets Mildly decreased 1.38 L - 1.5-4.5 X 10

 9/10

MCH 28.9

MCHC 33.8

MCV 86

PCV 26.0

RDW 11.8
 Liver function test

5/10 9/10 18/10

Bilirubin total (0.2-1.2 mg/dl) 1.0 1.0 1.1

Bilirubin direct (0.1-0.4 mg/dl) 0.4 0.4 0.5

Bilirubin indirect 0.6 0.6 0.6

 Serum electrolytes
5/10 7/10 9/10 17/10 18/10
Na+ 131 131 135 - 132 135-145 mEq/L
K+ 6.9 3.7 3.6 - 2.5 3.5-5.0 mEq/L
Urea 75 88 66 - 95 7-20 mg/dl
S. 1.53 1.66 1.28 - 2.48 0.5-1.2 mg/dl
Creatinine
Ca + - - - 7.8 - 8.5-10.2 mg/dl
Cor. Ca+ - - - 9.0 -
Specialised tests
• CRP: 12 microgram/ml
• Urine analysis : platelets- 4-5/hpf ;protein: present ; amorphous substance present
• Phosphorous: 9.0 (2.5-4.5)
• MRI: multifocal gliotic areas in bilateral frontal lobes. Hypodensity in bilateral
periventricular white matter-s/o periventricular ischemic changes.Age related
cerebrocortical atrophy
• 2D Echo : hypokinesia noted at anteroseptal and septal wall of LV
– Moderate LV systolic function with EF 45%
– Moderate MR AR grade V
– IVC normal in size and collapsing adequately with inspiration.
Corelation of data
• Patient came up with the complaints of pedal edema
which means that the condition is heart related. Along
with that the patient has a history of IHD. Also the
Echo and MRI shows ischemic changes and
hypokinesia which further confirms it.
• Also the patient shows increased levels of urea and
creatinine but no further tests were done.
Final diagnosis
Anasarca in K/C/O IHD with raw wound over the limbs.
 Problem list Goals of Therapy Need of therapy
• Breathlessness • Analgesic •it is a life threatening
• Bronchodilators problem which can kill a
• Anasarca person if left untreated
• Diuretics
• Abdominal
• Anti-emetic
pain
• Anti-
• Vomiting hypertensives
Current therapy
1.Inj. cefotaxime
Generic Name : Inj. Cefotaxime
Brand name:- Inj. cefotax
Dose :1 gm
Frequency: 8 hourly
Class : third generation cephalosporin
M/A :It shows bactericidal activity by inhibiting cell wall synthesis by binding to 1
or more cephalosporin binding proteins
Indications :To treat microbial infections
ADR's :Nausea, Headache , Diarrhea , dizziness
Drug-Drug Interactions : May increase nephrotoxicity of aminoglycosides. May
diminish therapeutic effect of BCG, typhoid vaccine. May increase anticoagulant
effect of vit K antagonists (e.g. warfarin).
2.inj. Lasix
Generic name: inj. Frusemide
Dose: 40 mg
Schedule: 8 hourly
Class: loop diuretics
Indications: diuretics
MOA: Loop diuretic; inhibits reabsorption of sodium and chloride ions at proximal and
distal renal tubules and loop of Henle; by interfering with chloride-binding
cotransport system, causes increases in water, calcium, magnesium, sodium, and
chloride
ADRs: hypokalemia, hyperuricemia,hypotension,diarrhoea,dizziness
Drug-drug interactions: aspirin, captopril, bisoprolol, chlorothiazide, enalapril
3. T. aspirin
Brand name: ecosprin 150
Dose: 150 mg
frequency: 0-1-0
Indications: antiplatelet
Class : antiplatelet and NSAIDs
MOA: inhibition of platelet function by acetylation of the platelet cyclooxygenase (COX)
at the functionally important amino acid serine. This prevents the access of the substrate
(arachidonic aid) to the catalytic site of the enzyme at tyrosine and results in an
irreversible inhibition of platelet-dependent thromboxane formation.
ADRs: severe nausea, bloody or tarry stools, heartburn, drowsiness, mild headache.
Drug-drug interactions: ibuprofen, warfarin, rivaroxaban
Drug-food interactions: caffeine, ethanol
Drug-disease interactions: asthma, GI toxicity, renal dysfunction, reye’s syndrome
4. Vasta
Generic name: atorvastatin
Dose: 20 mg
Schedule: 2 HS
Class: statins; HMG CoA reductase inhibitors
Indications: lowers levels of lipids
MOA:inhibits rate-limiting step in cholesterol biosynthesis by competitively inhibiting
HMG-CoA reductase
ADRs: diarrhoea, nasopharyngitis, arthralgia
Drug-drug interactions: cimetidine, carbamazepine, erythromycin, fenofibrate, anti-
fungals and anti-virals
Drug-food interactions: red yeast rice
5. T. sorbi
Generic name: isosorbide dinitrate
Dose: 10 mg
Schedule: 1/2 SOS SL
Class: nitrates
Indications: For the prevention of angina pectoris due to coronary artery disease.
MOA:Isosorbide dinitrate is converted to the active nitric oxide to activate guanylate cyclase.
This activation increases levels of cyclic guanosine 3',5'-monophosphate (cGMP). cGMP
activates protein kinases and causes a series of phosphorylation reactions which leads to
dephosphorylation of myosin light chains of smooth muscle fibres. Finally there is a
release of calcium ions which causes smooth muscle relaxation and vasodilation.
ADRs: headache, lightheadedness, hypotension
Drug-drug interactions: sildenafil
Drug-food interaction: alcohol
Drug-disease interaction: anaemia, hemodialysis, hypotension, intracranial pressure
6. CPM
Brand name: Avil
Dose: 4 mg
Schedule:0-0-1
Indications: anti-allergic
Class: histamine h1 receptor antagonist
MOA : Chlorpheniramine binds to the histamine H1 receptor. This blocks the
action of endogenous histamine, which subsequently leads to temporary relief
of the negative symptoms brought on by histamine.
ADRs : drowsiness, dizziness, constipation, stomach upset,
Drug-drug interactions: low strength aspirin, diphenhydramine, cetirizine
Drug-food interactions: alcohol and when taken with food
Drug-disease interactions: asthma, COPD, renal and liver disease
7.MVBC
Brand name:- neurobion forte
Frequency: OD
Dose : 5 mg
Class :vitamins
Indications : To overcome weakness
ADRs: tooth staining, muscle weakness, confusion
Drug-drug interactions: capecitabine, fluorouracil, warfarin,
sevelamer
8. T. sevelamer
Generic name:
Dose: 500 mg
Schedule: 1-1-1
Indications: lowers blood phosphorous levels
Class: phosphate binders
MOA: Sevelamer prevents hyperphosphatemia by binding to dietary phosphate in the
gut, preventing its absorption and thus decreasing serum parathyroid hormone
levels.
ADRs: nausea,vomiting, gas, joint pain
Drug-drug interactions: cholecalciferol, multivitamin, ofloxacin
Drug-food interactions: multivitamins with minerals, taken with food
Drug-disease interactions: GI disease, renal disease,dysphagia
9. Syp. Cremaffin
Generic name:Liquid paraffin, magnesium hydroxide, sodium picosulfate
Dose: 3.25 ml,3.75ml,33 mg
Schedule: 2 tspf TDS
Indications: easy passage of stools
class: laxative
MOA:gently stimulating the bowel muscles causing peristalsis and leads to ejection of
the bowel contents out of the body by lubricating and softening the stool.
ADRs:Fatigue, Dizziness, Diarhhoea, Cramps, and stomach aches
Drug-drug interactions:Furosemide, Ketaconazole, Prednisolone, Digoxin, Tetracycline
antibiotics
Drug-food interactions: alcohol
10. T. Pantop
Generic Name :Pantoprazole
Dose:40mg.
Frequency: BD
Class: proton pump inhibitor
MOA:PPI binds to H+/k+ exchanging ATPase in gastric parietal cells, resulting in
blockage of acid secretion .
Indication: antacid
ADRs: headache, abdominal pain, facial edema, chest pain, anorexia, cough
Drug- drug interaction: methotrexate, warfarin
Drug-disease interaction: C. Diff, liver disease
11. T. domstal
Generic name: domperidone
Dose:10 mg
Schedule: 1-0-1 sos
Indications: For management of dyspepsia, heartburn, epigastric pain,
nausea, and vomiting.
Class: dopamine receptor antagonist
MOA: Domperidone facilitates gastric emptying and decreases small bowel
transit time by increasing esophageal and gastric peristalsis and by
lowering esophageal sphincter pressure.
ADRs: dry mouth, abdominal cramps, nausea, rash, itching
Drug-drug interactions: alprazolam, azithromycin, itaconazole, ondanseteron
12.Atarax anti itch lotion
Generic name: hydroxyzine lotion
Class: antihistamine,sedative
MOA: Hydroxyzine competes with histamine for binding at H 1-receptor sites on the
effector cell surface, resulting in suppression of histaminic edema, flare, and
pruritus. The sedative properties of hydroxyzine occur at the subcortical level of
the CNS. Secondary to its central anticholinergic actions, hydroxyzine may be
effective as an antiemetic.
ADRs: headache with chest pain, tachycardia, seizure, severe rashes
Drug-drug interactions: sedatives, antibiotics, antidepressants, antipsychotics,
Drug-disease interactions: bradycardia, heart disease,long QT syndrome, electrolyte
imbalance,history of heart attack
Drug-food interaction: alcohol
13. T. prednisolone
Brand name: omnacortil
Dose: 5 mg
Schedule: 12 OD X 1 week ; 10 OD X 1 week ; 8 OD X 1 week …..
Indications: to reduce inflammation
Class: corticosteroids
MOA:inhibit inflammatory cells and suppresses expression of inflammatory
mediators.
ADRs: anxiety, dizziness, numbness in lower limbs
Drug-drug interactions: desmopressin, etanercept, gatifloxacin, nalidixic
acid, warfarin
Drug-disease interactions: hypertension, high cholesterol
14. amlodipine
Brand name: T. Amlo
Dose: 5 mg
Schedule: 1 OD
Indications: decreases blood pressure
Class: calcium channel blckers
MOA: inhibits ca+ mediated slow channel componenet of action potential in smooth
muscle cardiac cell leading to smooth muscle relaxation and negative chronotopic,
inotropic and dromotrpic action on heart.
ADRs: headache, constipation, rash, edema, low blood pressure
Drug-drug interactions: atorvastatin, carbamazepine, cyclosporine
Drug-food interactions: grapefruit juice
15. Bisacodyl
Brand name: dulcolex
Dose: 10 mg
Schedule: 0-0-1
Indications: treats constipation
Class: laxatives
MOA: Induces diarrhea which cleanses the colon.
ADRs: persistent nausea and vomiting,irregular heartbeat
Drug-drug interactions: low strength aspirin, lorazepam

Drug-disease interaction: IBD, intestinal obstruction disorders

16. T. tramadol
Brand name: contramol
Dose: 500 mg
Indications: ramadol is approved for the management of moderate to severe pain in
adults.
MOA: Tramadol is a centrally acting μ-opioid receptor agonist and SNRI
(serotonin/norepinephrine reuptake-inhibitor) that is structurally related to codeine
and morphine. It is a racemic mixture consisting of two pharmacologically active
enantiomers that both contribute to its analgesic property through different
mechanisms: (+)-tramadol and its primary metabolite (+)-O-desmethyl-tramadol
(M1) are agonists of the μ opioid receptor while (+)-tramadol inhibits serotonin
reuptake and (-)-tramadol inhibits norepinephrine reuptake.
Drug – drug interaction: aceclofenac, aspirin, acyclovir, albendazole, amlodipine
Drug-food interaction: can be taken without the regard of food
17. Acyclovir
Dose : 400 mg
Frequency: 1-1-1-1-1
Indication : used to treat viral infections
MOA: Acyclovir is becomes acyclovir monophosphate due to the action of viral
thymidine kinase. Acyclovir monophosphate is converted to the diphosphate form by
guanylate kinase. Acyclovir diphosphate is converted to acyclovir triphosphate by
nucleoside diphosphate kinase, pyruvate kinase, etc. Acyclovir triphosphate has
higher affinity for viral DNA polymerase than cellular DNA polymerase and
incorporates into the DNA where the missing 2' and 3' carbons causes DNA chain
termination.
ADRs: coma,agitation, seizures, lethargy and precipitation in renal tubules
Drug-drug interactions: paracetamol, cefoxitin,ceftazidime,chloramphenicol
Drug-food interactions: increases fluid intake, take without regard with meals
 Discharge Medications
T. Amlo 5 mg 1OD Syp. Cremaffin 2 tsf TDS
T. Aspirin 300 mg 0-1-0 T. Pantop 40 mg 1-0-1
T. Vasta 20 mg 2 HS T. Domstal 10 mg 1 sos
T. Lasix 40 mg 1-0-0 Atarax anti-itch lotion
T. Sorbi 10 mg ½ sos SL White paraffin gel
T. CPM 4 mg 1-0-1
T. Ca++ 500 mg 1-1-1
T. Sevelamer 500 mg 1-1-1
T. MVBC 5 mg 0-1-1
Pharmacist interventions
• The patient is on and off of many drug /therapy the doctor might have to find a specific
drug /therapy.
• Some of the drugs which are not given during the therapy but are given in the discharge.
• Prednisolone was given but was then stopped suddenly. This might cause side effects. This
drug should be added in the discharge also.
• Urea and creatinine is increased but no further tests are done.
• Patient was advised for augmentin, deflazacort but they were not given.
• Patient was given bisacodyl, liq. Cremaffin and enema but stool was passed without them
also these should be given sos.
• Patient was given discharge prescription without looking at the tests.
• Patient wasn’t checked for RBS after giving dextrose inj.. Also the patient wasn’t further
checked for hypo/hyperglycemia.
 Monitoring parameters
• Monitor closely
– atorvastatin +prednisolone - atorvastatin will increase level or effect of prednisolone by P-
glycoprotein efflux transporter.
– Chlorphenniramine + traamdol – both increase sedation
– Prednisolone+ atorvastatin – prednisolone will decrease levels of atorvastatin by effecting
hepatic/intestinal enzymes CYP3A4 metabolism.
– Hydroxyzine + tramadol - increase sedation
– Hydroxyzine + ondanseteron – hydroxyzine increases toxicity of ondanseteron by QTc
interval. Increase risk of torsades de pointes
– Chlorpheniramine + hydroxyzine – increase sedation
• Minor
– Furosemide + magnesium hydroxide – furosemide decreases levels of magnesium hydroxide
by increasing renal clearance.
– Prednisolone + furosemide – works by pharmacodynamic synergism. Risk of hypokalemia,
especially with strong glucocorticoid activity.
• Atorvastatin and anti-virals interact with each other either
the dose should be decreased or one of them is to be stopped.
• Sevelamer and multivitamns interact with each other either
the dose should be decreased or one of them is to be stopped.
• Acetylsalicylic acid may decrease excretion of tramadol
• Acyclovir may decrease excretion of tramadol.
• Serum concentration of amlodipine is increased by tramadol.
Patient counseling
• Disease related
– Patient is told about the condition and the
complications of it.
– Patient is also told that the condition is chonic and
may worsen if not managed properly.
• Drug related
– T. amlodipine is to be taken once daily. The tablet is to be taken once every day
at a specific said time.
– Aspirin is to be taken once in the afternoon.
– Lasix is to be taken once In the morning.
– sorbitrate is to be taken sos whenever there is a chest pain.
– CPM is to be taken twice a day. It should be taken one hour before meals or 3
hours after meals.
– sevelamer and Ca++ is to be taken thrice a day. Sevelamer is to be taken one
hour before meals or 3 hours after meal
– T. pantop is to be taken twice a day. It is to be taken half an hour before the
meals.
– T. domstal is to be taken sos whenever the patient feels nausea and vomiting.
– Atarax lotion and paraffin gel is to be applied after cleaning wound and hands
are to be washed after applying the lotion. The lotion can be applied twice a day.
• Patient related
– Patient is told to immediately report to the doctor for help if there is
increased heartbeats, vomiting and some other symptoms which are
unexpected.
– Controlling the amount of salt in the diet (<2,000mg) is relevant in the
patients.
– The patient should be encouraged to, and advised how to, carry out
daily physical and leisure-time activities that do not induce symptoms, in
order to prevent muscle de-conditioning.
– Patients are advised to weigh on a regular basis (once a day to twice a
week) and, in case of a sudden unexpected weight gain of more than
2kg in three days, to take appropriate action.
– Non-pharmacologic techniques for stress reduction may be considered
as a useful adjunct for reducing anxiety.