Case presentation on CAD

Evaluation of case in SOAP FORMAT.

1. CASE PRESENTATION ON CORONARY ARTERY DISEASE PRESENTED BY: CH.BINDU MADHAVI II/VI PHARM D Y17PHD0805 DEPARTMENT OF PHARMACY PRACTICE NIRMALA COLLEGE OF PHARMACY

2. Brief summary about the case: A male patient of age 65 yrs was admitted in the hospital with the c/o shortness of breath –grade II, palpitations, urinary frequency and is having a past history of type 2 DM and he is diagnosed that he is having mild CAD with triple vessel disease. followed by standard treatment the patient was normalised. The above case was presented in the format of SOAP ANALYSIS.

3. Subjective evidence : A male patient of age 65 yrs was admitted in the hospital with c/o SOB(grade –II) , palpitations, urinary frequency. A nd is having a past history of type-2 DM. His appetite and sleep are normal.

4. OBJECTIVE evidence : Physical examinations: BP-110/80 mm Hg R.R-18 cycles/min P.R-84 beats/min Pt : conscious Systemic examinations: Temp-normal CVS - SP - 98% on room air  

5. Laboratory investigations : Haematology Abnormal values Normal values Hb 12.7g/dl ( ) 14-18 gm /dl Haematocrit (PCV) 40% ( ) 42-54% Mean corpuscular haemoglobin(MCH) 26.9pgm ( ) 27-31pgm Red cell distribution width (RDW) 15.6% ( ) 11.6-14% Mean cell Hb conc (MCHC) 31.8g/dl ( ) 32-37g/dl Differential count Abnormal values Normal values Neutrophils 77% ( ) 40-75% Lymphocytes 18% ( ) 20-45%

6. DIAGNOSTIC TEST : Coronary angiogram report: n Impression :CAD mild [MCA + critical triple vessel disease] Left anterior descending artery Left Circumflex artery Right coronary artery parameter profile Abnormal values Normal values TSH 5.540 mic IU/ml ( ) 0.4 - 4 mic IU/ml

7. Assessment : Based on the subjective and objective data the final diagnosis was found to be CAD(coronary artery disease) DEFINITION: CAD is caused by atherosclerosis of the coronary arteries that lead to a restriction of blood flow to the heart. ETIOLOGY: The major causes for the CAD in the above case is due to DM. Etiological factors for CAD are: Smoking Hypertension Diabetes

8. RISK FACTORS: High blood cholesterol and TG levels Diabetes and obesity Smoking Lack of physical activity Unhealthy diet Stress

9. Pathophysiology: Due to etiological factors ,which causes injury to the endothelial cells that line the artery. Oxidised LDL enters the artery intima and there is accumulation of lipids in the arterial wall . Accumulation of lipids causes narrowing and obstruction of blood vessel. Thrombus obstruct the flow leading to sudden cardiac death or MI It may cause angina and other symptoms.

10. Clinical presentations : Chest pain(angina pectoris) MI Palpitations Dysarrithmiasis Chest heaviness Dyspnea Shortness of breath Fatigue

11. STANDARD TREATMENT: PHARMACOLOGICAL THERAPY: Anti anginal medications like: Nitrates (ISD) β- adrenergic blockers(Atenolol) Calcium channel blockers (nefidipine) ACE inhibitors(captopril) Statins Imipramine for analgesia Diuretics SURGERY’S Coronary angioplasty Coronary artery bypass graft(CABG) Heart transplant Stents

12. Plan : GOALS: The goal of the treatment is to alter the atherosclerotic progression and further complications The aim is to reduce serum cholesterol and TG levels. To prevent the signs and symptoms by symptomatic therapy.

13. CURRENT DRUG CHART: S .NO BRAND NAME GENERIC NAME D OSE ROUTE OF ADMINISTRATION FREQUENCY DURATION D1 D2 D3 D4 1. Inj.Lasix Inj.Furosemide 20 mg IV BD 2. T.Lanoxin T.Digoxin 0.25mg Per oral OD 3. Inj.Hep-pak Inj.Heparin 5000U IV TID 4. T.Plavix T.Clopidogrel 75mg Per oral OD 5. T. Amaryl M T. Glimepiride Metformin 2/500mg Per oral OD USE Used to treat fluid retention Used to control ventricular response rate. Used to prevent blood clots Used in treatment of thrombosis. Used to reduce blood glucose levels

14. Drug information S.NO NAME OF THE DRUG CATEGORY MECHANISM OF ACTION ADVERSE EFFECTS MONITORING PARAMETERS 1. Inj. Furosemide (Inj. Lasix) Loop diuretic Blocks the absorption of , and O from the filtered fluid. Low BP, dehydration , elelectrolyte depletion. Monitor wt daily,BP,serum electrolytes,renal function. 2. T. Digoxin (T. Lanoxin ) Cardiac glycoside Increases the force of contraction of muscle of heart by inhibiting the activity of an enzyme ATPase . Nausea, vomiting,diarrhea,head ache, dizziness ,skin rash. Heart rate and rhythm should be monitored along with periodic ECG. 3. Inj. Heparin (Inj. Hep - pak) Heparinoids (class anti –coagulants) Prevents fibrin formation and inhibits thrombin induced activation of platelets. Bleeding , osteoporosis, hyperkalemia,asthma,nausea,vomiting. Periodic monitoring of platelet count every 2-3 days 4. T. Clopidogrel (T. Plavix) platelet aggregation inhibitors . Inhibits binding of ADP to its platelet receptor. Thrombotic,rashes,itching Signs of bleeding ,haemoglobin are monitored. 5. T. Glimepiride Metformin (T.Amaryl M ) Sulfonyl urea Biguanide Glimepiride reduces glucose output from the liver . Metformin decreases hepatic glucose production. Diarrhea,dizziness,hypertension,nausea, vomiting,head ache. Monitor for signs and symptoms of hypoglycaemia,sweating,numbness,renal function. S.NO NAME OF THE DRUG CATEGORY MECHANISM OF ACTION ADVERSE EFFECTS MONITORING PARAMETERS 1. Inj. Furosemide (Inj. Lasix) Loop diuretic Low BP, dehydration , elelectrolyte depletion. Monitor wt daily,BP,serum electrolytes,renal function. 2. T. Digoxin (T. Lanoxin ) Cardiac glycoside Increases the force of contraction of muscle of heart by inhibiting the activity of an enzyme ATPase . Nausea, vomiting,diarrhea,head ache, dizziness ,skin rash. Heart rate and rhythm should be monitored along with periodic ECG. 3. Inj. Heparin (Inj. Hep - pak) Heparinoids (class anti –coagulants) Prevents fibrin formation and inhibits thrombin induced activation of platelets. Bleeding , osteoporosis, hyperkalemia,asthma,nausea,vomiting. Periodic monitoring of platelet count every 2-3 days 4. T. Clopidogrel (T. Plavix) platelet aggregation inhibitors . Inhibits binding of ADP to its platelet receptor. Thrombotic,rashes,itching Signs of bleeding ,haemoglobin are monitored. 5. T. Glimepiride Metformin (T.Amaryl M ) Sulfonyl urea Biguanide Glimepiride reduces glucose output from the liver . Metformin decreases hepatic glucose production. Diarrhea,dizziness,hypertension,nausea, vomiting,head ache. Monitor for signs and symptoms of hypoglycaemia,sweating,numbness,renal function.

15. Drug interactions: Moderate: 1.FUROSEMIDE AND DIGOXIN: These are often used together but may require more frequent evaluation of digoxin ,potassium and magnesium levels. It may cause symptoms like weakness,tiredness,muscle pains or cramps,nausea ,decreases appetite, visual problems or irregular heart beats. Management: avoid co-administration of drugs. 2.DIGOXIN AND METFORMIN: Digoxin together with metformin may increase the effects of metformin ,which leads to lactic acidosis. Causes symptoms like weakness,slow heart beat, muscle pain ,SOB, stomach pain . Management : avoid co-administration of drugs and monitor levels of metformin.

16. 3.FUROSEMIDE AND METFORMIN: Furosemide together with metformin may increase the effects of metformin, which leads to life-threatening condition called lactic acidosis. It includes symptoms like weakness, increasing sleepiness, slow heart rate,SOB,stomach pain. Management : avoid co-administration of drugs and monitor levels of metformin. 4.FUROSEMIDE AND GLIMEPIRIDE: Furosemide interfere with blood glucose control and reduce the effectiveness of glimepiride. Management: check the dose adjustment of your diabetic medications during and after the treatment with furosemide.monitor the blood glucose levels.

17. 5.HEPARIN AND GLIMEPIRIDE: Heparin can increase the effects of glimepiride and cause your blood sugar levels to get low. Symptoms include headache, dizziness, drowsiness, nausea, hunger, sweating, tremors. Management: need a dose adjustment and monitor the levels of blood sugar.

18. PATIENT COUNSELLING : ABOUT THE DISEASE: CAD is caused by atherosclerosis of the coronary arteries that lead to a restriction of blood flow of the heart. CAD is caused mainly due to : Smoking diabetes mellitus Hypertension high cholesterol over weight etc.

19. About the drugs: FUROSEMIDE- should be taken with food because the levels of furosemide may decrease in presence of food. DIGOXIN- should be taken with food .meals containing increased fibre or foods high in pectin may increase oral absorption of digoxin. HEPARIN- should not be given into the muscle. CLOPIDOGREL- Consumption of three 200ml glasses of grape fruit juice a day may reduce clopidogrel effect.so it is better to avoid or minimize the consumption of grapefruit juice. GLIMEPIRIDE- should not be taken with ethanol .because ethanol may cause rare disulfiram reactions. METFORMIN- should be taken with a meal because it decreases the extent and slightly delays absorption .since metformin causes GI upset it is taken with food.

20. About life style modifications : STOP SMOKING: smoking is toxic to your heart and blood vessels. EAT A HEALTHY DIET: a diet that is low in fat, cholesterol, salt and sugar. EXERCISE: exercising at a moderate intensity just for 30 minutes a day ,five days a week. STRESS MANAGEMENT: anger , depression and anxiety are linked to heart diseases. DECREASE OR DISCONTINUE ALCOHOL CONSUMPTION: excess alcohol increases TG levels in blood which lead to atherosclerosis.

21. REFRENCES: www.mayoclinic.org www.coronaryarterydiseasewikipedia.org www.medscape.com www.uptodate.com Drugs.com

22. ANY Queries?