Coronary artery disease-Triple vessel disease

Triple vessel disease

1. A CASE PRESENTATION ON TRIPLE VESSEL DISEASE CLERKSHIP ASSESSMENT -III DEPARTMENT : CARDIOLOGY 1

2. DEMOGRAPHIC DETAILS : NAME : XYZ AGE : 67 years D.O.A:10/07/17 SEX : M DEPT : CARDIOLOGY D.O.D: 14/07/17 CHIEF COMPLAINTS : c/o left sided chest pain ; since 3days increased pain since 8:00 am associated with sweating,pain radiating to left hand PAST MEDICAL HISTORY : since 5 years HTN ( on TELMISARTAN 20mg) T2 DM (on metformin 500mg) 2

3. GENERAL EXMANINATION : o/e pt c/c temp : afebrile SYSTEMIC EXAMINATION : BP : 150/100 mm Hg PR : 64 /min RESP : BAE+ CVS : S1+S2+ PROVISIONAL DIAGNOSIS: CAD -ACUTE INFEROPOSTERIOR MYOCARDIAL INFARCTION 3

4. SYMPTOMATIC TREATMENT 1.Tab. ASPIRIN 325mg stat PO antiplatelet 2.Tab.TICAGRELOR 180mg stat PO antiplatelet 3.Tab.ATORVASTATIN 40mg OD PO hypolipidemic 4.Inj.HEPARIN 5000IU TID IV anticoagulant 5.Inj.NITROGLYCERIN 0.3ml/hr(each ml contain 5mg) 6.Inj.NS 1 pint 50ml/hr 4

5. LABORATORY INVESTIGATIONS : Hb - 12g% (N : 12-18g%) Blood urea – 54 mg/dl (N : 10-50mg/dl) serum creatinine - 1.8 mg/dl (N: 0.5-1.5mg/dl) Troponin .T - 0.31ng/ml (N : <0.03ng/ml) 2D ECHO : Inferoposterior wall hypokinetic,Moderate left ventricular dysfuncion,LVEF(40%),CAD CORONARY ANGIOGRAM : Triple vessel disease FINAL DIAGNOSIS : CAD /TRIPLE VESSEL DISEASE 5

6. On 11/07/17 Advice : PCI with stent to Posterior Descending Artery(PDA),Left Circumflex Artery, Posterior Left Ventricular Artery(PLV) FOLLOW UP : o/e pt c/c temp: N BP:160/90mmHg P/A : soft CVS : S1+S2+ TREATMENT : 1. Tab . ASPIRIN 75mg PO OD 2. Tab. TICAGRELOR 90mg PO BD 3. Tab.ROSUVASTATIN 40mg PO OD 4. Inj . HEPARIN 5000IU IV QID 5. Tab. NEFROSAVE 150/500mg PO BD 6. Inj.NTG @0.3ml/ hr IV 7 . Inj.CEFAZOLINE 1g IV TID 8 . Inj . NS 1pint IV 50ml/hr 6

7. On 12/07/17 pt c/c BP: 140/80mm Hg CVS :S1+S2+ PR : 67/min RS : BAE + TREATMENT : continue same treatment add : tab. CILNIDIPINE 10mg PO OD tab. NITROGLYCERINE SR 2.6mg PO BD Inj. PANTOPRAZOLE 40mg IV OD On 13/07/17 pt c/c c/o restlessness BP : 130/90mmHg CVS : S1+S2+ PR : 81/min advice : stop Inj.NTG add tab.ALPRAZOLAM 0.25mg sos 7

8. CORONARY ARTERY DISEASE( TRIPLE VESSEL DISEASE) Heart muscle is supplied with three major coronary arteries i.e.,left anterior descending,left circumflex,right coronary artery. In posterior wall myocardial infarction the major artery assosiated is right coronary artery and its branch (postetior descending artery) Acute coronary syndrome includes Unstable angina,NSTE MI,STE MI. The cause is erosion or rupture of an atherosclerotic plaque with subsequent platelet adherence. Patients who smoke, or having diabetes or HTN and with high blood cholesterols are more prone to CAD . The obstruction of oxygen rich blood flow to myocardial cells leads to necrosis and may lead to heart failure. 8

9. GOALS OF THERAPY : P ain management (with nitroglycerin 3 doses,if not releived then with morphine) Prevention of death. M aintenance of blood volume/tissue perfusion(with normal saline or dextran) Prevention and treatment of arrythmias(with i.v .beta blockers) P revention of future attacks 9

10. STANDARD TREATMENT :(ACC/AHA Guidelines) Oxygen inhalation ( if oxygen saturation is <90%) Aspirin (160-325mg) sublingual NTG (0.4 mg every 5min for 3 doses ) High risk patients(as per TIMI score) should proceed to early coronary angiography ) Anticoagulant(UFH/ enaxoparin / fondaparinux ) to patients with NSTE ACS undergoing PCI to reduce risk of intracoronary and catheter thrombus formation . I.V beta blockers (if not contraindicated) and I.V Nitroglycerine ( to patients with persistent ischemia or heart faliure or hypertension) should be given to selected patients. I.V Nitroglycerin (5-10mcg/min titrated upto 75-100mcg/min until relief of symptoms ) In patients with NSTE ACS continuing or frequently recurring ischemia and a contraindication to beta blocker a non dihyropyridine CCB(verapamil , diltiazem)should be given as initial therapy(to relieve coronary artery spasm) Fibrionlytic therapy is indiacted in STE MI but is not in any patient with NSTE ACS.Because risks of fibrinolytic therapy(bleeding overweigh the benifit for NSTE ACS patients) 10

11. According to TIMI score and GRACE score high risk patients should undergo early angiography (within 12 to 24 hrs) and revascularization ( with percutaneous coronary intervention/CABG) if significant coronary artery stenosis is found. Moderate risk patients with positive biochemical markers for infarction also will undergo angiography and revascularization . Patients undergoing PCI should take 325mg aspirin before PCI and a loading dose of P2Y12 receptor inhibiotors given before procedure in patients undergoing PCI with stenting : clopidogrel 600mg or prasugrel 60mg or Ticagrelor180mg DUAL ANTIPLATELET THERAPY(DAPT) In patients with ACS ,treat with DAPT after stent implantation,P2Y12 inhibitor therapy( clopidogrel/prasugrel/ticagrelor)should be given for atleast 12 months In Patients with DAPT ,daily aspirin dose of 81mg(range 75mg to 100mg) is recommended After stent implantation it is reasonable to use ticagrelor in preferrable to clopidogrel. 11

12. An ACE inhibitor should be started within 24hrs of presentation particularly if LVEF <40 % and in those with HTN/ DM/CKD. High intensity statin therapy should be initiated or continued in all patients with ACS and no contraindications to its use. As per guidelines ,after an ACS all patients should recieve DAPT therapy ideally for 12months followed by lifelong aspirin therapy. GOALS ACHEIVED : Reduction of signs and symptoms Reperfusion done with stent implantation in three vessels. 12

13. INTERVENTION : Aspirin plus Heparin leads to increased risk of bleeding. Before administration of Heparin, aPTT should be monitored and the dose should be adjusted based on the aPTT. Regular monitoring of aPTT is necessary when patient is on Heparin. short acting Dihydropyridine calcium channel blockers (clinidipine) contraindiacted in this case. (according to ACC guidelines) DRUG -DRUG INTERACTION: Atorvastatin +pantoprazole increases side effects of atorvastatin by increased levels of atorvastatin in blood.Increased risk of musculoskeletal toxicity.Therapy should be discontinued if Creatinine kinase is markedly elevated. 13

14. DISCHARGE MEDICATION : Tab.ASPIRIN 75mg OD Tab.TICAGRELOR 90mg OD Tab.ATORVASTATIN 40mg OD Tab. CLINIDIPINE 10mg OD Tab. NITROGLYCERINE 2.6mg BD Tab.PANTOPRAZOLE 40mg OD Tab. ALPRAZOLAM 0.25mg SOS 14

15. PATIENT COUNSELLING : Dont stop aspirin on your own. As it is life saving. It may be a life long therapy Take atorvastatin at night after meals. Nitroglycerine tablet may cause hypotension.Dont drive or operate machines while on nitroglycerine. If u feel lightheadedness or any hypotensive features immediately report to physician. It is potentially fatal when taken with alcohol. Take alprazolam at nights,when u feel restlessness(not more than one dose). Control major risk factors (Diabetes, smoking,cholesterol,HTN) Regularly use Antihypertensives and hypoglycemic agents. control your HTN by reducing intake of sodium to not more than 2400mg/day,moderate alcohol consumption,low fat intake,limitation of saturated and trans fat,regular exercise,body weight control(as per JNC 8 guidelines). 15

16. THANK YOU PRESENTED BY K.ARUN PHARM.D V YEAR 13371D1009 VAAGDEVI INSTITUTE OF PHARMACEUTICAL SCIENCES 16