cardio case (2)

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UNDER SUPERVISION OF:

Professor/ Osama Ibrahim

BY : Sarah Agiza Mohammed Adel Nedaa Nader

Heart failure Case

Presentation

2Content History of present illness Past medical historyDrug history Chief complaint

3Content Family & social historyVital signs Labs & investigationsTreatment strategy Clinical pharmacy

interventions

4History of present illness

Room 2 , S.A is a 27 YO Egyptian male admitted to Ahrar General Hospital complaining of moderate to severe dyspnea and fever . He was referred by his physician after exaggeration of his dyspnea.

5Past medical history

STEMI 2 months ago (PCI to LAD) which lead to Idiopathic dilated cardiomyopathy

Echo screen revealed 29% EF

Past medications Plavix® 75 mg P.O tab. Q.D Aspocid ® 150 mg P.O tab. Q.D Lasilacton ® 40 mg P.O. tab BID

Pt. words

6Chief Complaint

Dyspnea Fever Cough (productive)

7Family historyN/A

Social History

Smoking cannabis

8Vital signsVITAL SIGNSTemperature 38.5 0cPressure 90/60 mmHg Pulse 75 BpmRespiratory rate 23 Breaths/min

9InvestigationsLab tests

Test name

Reference range 29/3 31/3

3/4 6/4

TLC 4-11 ×103 cell/cc 10.5 N/A N/A N/AHgb 13.5-17 gm/dL 11.6 N/A N/A N/A

PLT 150-350 ×103 cell/cc

268 N/A N/A N/A

Bil.T. 0.2-1 mg/dL 1.8 1.3 .9 1.23AST Up to 40 U/L 140 53 20 41ALT Up to 40 U/L 176 79 26 26

10Investigations

Lab testsTest name

Reference range 29/3 31/3

3/4 6/4

Urea 15-20 mg/dL 30 24 28 48Cr. 0.6-1.2 mg/dL 1.1 0.8 0.76 0.96Cr.Cl 100-140 ml/min 97.0

2133

140 111

Na+ 135-145 mmol/L 138 N/A N/A 136K+ 3.5-5 mmol/L 3.9 53 20 3.8Trop. Up to 40 U/L -ve N/A -ve N/A

11Investigations

Lab tests Sputum Culture/Sensitivity test:E.Coli with extended spectra β-Lactamase enzyme (ESBL) which is sensitive to:

Amikacin Meropenem Imipenem Tigecycline

12Investigations

Lab tests Sputum Culture/Sensitivity test:E.Coli with extended spectra β-Lactamase enzyme (ESBL) which is resistant to:

Cephalosporins Fluoroquinolones Macrolides Vancomycin

13Investigations

Chest CT scan revealed: Pulmonary edema Pneumonic patches on both lungs Mild pleural effusion

14Diagnosis

S.A suffers from pulmonary edema as a result of Left ventricular failure complicated with chest infection and barely controlled hypotension with IV. Dobutamine

15Hospital medications

The health care team accepted the following strategy for the management of S.A:Resume anti-ischemic therapiesStart anti-failure therapies Obtain sputum sample for C/S test

and start empirical antibiotic therapy

16Hospital medications

anti-ischemic therapies include:Clopidogrel 75mg P.O tablet QDAspirin 75 mg P.O 2 tablets QDAtorvastatin 40 mg P.O tablet QD

17Hospital medications

Anti-failure therapies include:Captopril 6.25mg P.O tablet TIDFurosemide 20 mg IV. Ampoule TIDSpironolactone 25 mg P.O tablet QD

then up titrate by 25 mg increment.Dobutamine 100 mcg/min IV infusion

for 1hr then adjust

18Hospital medications

Empirical anti-biotic therapies include:Ceftazidim 1gm IV. Vial Q.8hrsCiprofloxacin 400 mg IV. Ampoule

Q12hrs

19Hospital medications

Culture guided anti-biotic therapies include:Meropenem 1gm IV. Vial Q.12hrsAmikacin 500 mg IV. Ampoule Q12hrs

20Hospital medications

Adjunctive therapies include:Enoxparin 40mg S.C syringe Q24hrsRanitidine 50mg slow IV. amp Q.8hrsMetoclopramide 10mg IV. Amp PRN

nausea Paracetamol 500mg IV. Bottle PRN

fever

21Drug interaction review

All drug interactions found are class C that barely influence the clinical decision for this patient

22Optimization the therapy

Meropenem frequency should be increased to Q.8hrs

Add Bisoprolol 1.25 mg P.O tablet QDDecrease atorvastatin dose to 10mg

QDClose monitoring of liver function

test & kidney function tests.Order CBC count

23Facts and comparisons

Captopril Furosemide

Class ACE inhibitors Loop diureticAbsorption rapid rapidBioavailability

60-70% 47-64%

Peak Cp One hr P.O1st to 2nd hr

PP bind 25-30% 91-99%T ½ 1.7hrs .5-2 hrsExcretion renal renal

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