Pathophysiology Concepts:
Hypertension (primary, no discernible cause) and hyperlipidemia (LDL cholesterol especially) damage the arterial endothelium and lead to atherosclerosis.
Atherosclerosis is a systemic disease of the major arterial systems: cerebral, coronary, and peripheral.
Atherosclerosis narrows the artery, in this case the coronary artery, and decreases myocardial oxygen supply. This is complicated by anemia, which further decreases oxygen supply.
Pharmacotherapy is directed at controlling hypertension (HCTZ and CCB), treating hypercholesterolemia (atorvastatin), and preventing a first cardiac atherosclerotic event (aspirin)
Case Presentation
Reason for the encounter: The patient is a 52-year-old peri-menopausal person who is at a primary care clinic for a routine annual exam.
Vital signs: Interpret these
98.6-86-16-168/94 (RA) -99% (current visit); BMI: 32
97.6-80-20-150/92 (RA) – 99% (one year ago); BMI: 30
98.4-76-18-156/82 (RA) – 99% (two years ago); BMI: 28
History:
Medical: Irregular menses
Surgical: NA
Social: Lives with spouse, two teenage children; does not smoke, drinks occasionally.
Family: Mother deceased, COD stroke; father deceased, COD heart attack; sister alive, renal insufficiency.
Labs: Place arrows up/down for values that are outside the range of normal and interpret the results.
BMP CBC
Na 142 mOsm/L WBC 9.8
K 3.9 mOsm/L RBC 2.9
Cl 105 Hemoglobin 9
CO2 24 Hematocrit 27
BUN 15 MCV 68
Creatinine 1.2 MCHC 25
eGFR 53 mLs/minute Platelet 220
FBS 136
Allergies: No known allergies
Med List:
Drug: Generic (Trade) Dose Route Indication
Acetaminophen (Tylenol) 500 – 1000 mg every 8 hours prn Oral HA, pain, fever
Ibuprofen 200-600 mg every 8 hours prn Oral HA, pain, fever
List four medical diagnoses that are evident from the case. Provide evidence.
Physical exam:
Constitutional: Appears well.
HEENT: Normocephalic; PERRLA, red reflex and vessels visible; canals clear, drums pearly gray; mucus membranes moist, teeth in good repair; neck supple, thyroid not palpable.
Cardiac: Skin warm, distal pulses 2+, no edema; S1, S2, + S4, no murmur/rub.
Respiratory: Chest symmetrical, vesicular sounds in periphery, no crackles or wheezes.
Abd: Obese, no scars; BS + in four quadrants; percussive note tympanic; no masses.
GU: Deferred.
Extremities: Feet warm, no lesions, dorsalis pedis and posterior tibial 2+, no neuropathy.
Draw a concept map demonstrating the relationship between the diseases. Concept maps vary among courses. Do not get hung up on that.
Circles
Below the circles data from the case to support the diagnosis
Use arrows to indicate cause and effect relationship between the medical conditions. A solid arrow means the relationship is well established; a dashed arrow indicates a relationship that is possible.
The patient leaves her appointment with the following prescriptions.
Drug: Generic (Trade) Dose Route Indication
Ferrous sulfate 324 mg daily oral Iron deficiency anemia
Hydrochlorothiazide 25 mg daily oral Hypertension
Nifedipine SR 30 mg daily oral Hypertension
- The patient asks how a diuretic and calcium channel blocker will lower blood pressure. Look at the blood pressure formula and think about how the drug works. Use the green highlighter to identify which component of the BP formula the drug changes and in which direction (up or down).
Hydrochlorothiazide
BP=(HR x SV) X R
Nifedipine SR
BP=(HR x SV) X R - The patient asks what side effects she might expect based on these drugs in combination and each drug individually.
Use Lexicomp to determine drug interactions.
Use notes and text to address each drug individually. Pick no more than three side effects based on the drugs mechanism of action. Side effects
HCTZ and nifedipine in combination
HCTZ alone
Nifedipine alone - When should the patient’s BP be re-evaluated and what is the goal BP (See lecture notes, Blood Pressure Thresholds and Recommendations for Treatment and Follow Up)?
Re-evaluation: _
BP goal: ___
To evaluate the patient’s risk for atherosclerotic cardiovascular disease the provider orders a lipid panel. The results are listed below. Which type of cholesterol contributes to atherosclerotic disease?
LIPID PANEL
Cholesterol total 265 mg/dL
Triglyceride 100 mg/dL
HDL cholesterol 26 mg/dL
LDL cholesterol 170 mg/dL
The following medicines are added.
Drug: Generic (Trade) Dose Route Indication
Aspirin 81 mg daily oral Primary prevention, MI
Atorvastatin 20 mg daily oral Hyperlipidemia
Ferrous sulfate 324 mg daily oral Iron deficiency anemia
Hydrochlorothiazide 25 mg daily oral Hypertension
Nifedipine SR 30 mg daily oral Hypertension
Look at p. 566 of text. This algorithm shows the major indications for statin therapy. They are: clinical ASCVD, LDL-C > 190 mg/dL, diabetes, and 10 year ASCVD risk estimate. She does not meet the first three criterion but she’s darn close.
- Figure out her 10-year risk using the data provided and this risk calculator http://tools.acc.org/ascvd-risk-estimator-plus/#!/calculate/estimate/. The case does not provide a race or smoking history so make them up.
There are significant concerns about using race for risk assessment. Here’s one example with heart failure where being non-black increases the risk score and tilts treatment away from Blacks. - Serious adverse effects with atorvastatin are infrequent. Fill in the table below to remind yourself of the adverse effects, relative frequency, patient symptoms, and lab testing (Use notes and text p. 571).
Adverse effect Frequency Symptoms Lab evaluation
Myopathy
Hepatotoxicity - Aspirin is indicated for a variety of conditions including pain, fever, and antiplatelet effect. What is it about the dosing and frequency of aspirin that makes it for primary prevention of MI and not for pain or fever?
- The patient asks if it matters whether she takes the medicines in the morning or evening and with regard to meals. Think about the drugs, their mechanisms of action, potential adverse effects and any additional information that might help provide a reasonable answer. For each drug, select only one recommendation and provide a rationale.
Drug Recommendation
Morning dosing Evening dosing With meals
Aspirin
Atorvastatin
Hydrochlorothiazide
Nifedipine SR
Unfolding Case Study Part Two: The Same Patient with ASCVD and Cardiac Ischemia
Pathophysiology Concepts:
Ischemic Heart Disease: Acute coronary syndrome
Oxygen supply (decreased due to atherosclerosis of coronary arteries) and demand (increased due to hypertension and tachycardia). The imbalance leads to ischemia, injury, and if not corrected, myocardial infarction.
Hemodynamics and their effect on myocardial oxygen demand
Preload: End diastolic volume
Contractility: Force of cardiac muscle shortening (contraction)
Afterload: Resistance to the ejection of blood
Mechanisms of clot
formation: Platelet aggregation (arterial) and activation of clotting cascade (venous)
dissolution: Activation of plasminogen
Pharmacology is directed at increasing myocardial oxygen supply (oxygen, aspirin) and reducing oxygen demand (HCTZ and NTG to reduce preload, nifedipine to reduce blood pressure and afterload, metoprolol to reduce contractility and heart rate) and increasing supply (alteplase to disintegrate coronary artery thrombosis and heparin and warfarin to prevent recurrence of thrombosis)
Case Presentation
Reason for the encounter: The patient is now 57 years old and is seen in the Emergency Department for episodes of indigestion, nausea, diaphoresis and chest discomfort that occur at rest and when active.
Vital signs in 15-minute intervals most recent first. Interpret these. What’s different compared to earlier vital signs?
98.6-110-16-148/88 (RA) -99% (current visit); BMI: 35
97.6-100-20-144/86 (RA) – 99%; BMI: 35
98.4-102-18-156/86 (RA) – 99%; BMI: 35
History:
Medical: Post-menopausal; HTN; ASCVD; Diabetes mellitus type 2
Surgical: NA
Social: Lives with spouse; does not smoke, drinks occasionally.
Family: Mother deceased, COD stroke; father deceased, COD heart attack; sister alive, renal insufficiency.
Labs: Place arrows up/down for values that are outside the range of normal and interpret the results.
BMP CBC
Na 140 mOsm/L WBC 9.0
K 5.1 mOsm/L RBC 3
Cl 100 Hemoglobin 8.9
CO2 24 Hematocrit 27
BUN 15 MCV 75
Creatinine 1.4 MCHC 28
eGFR 43 mLs/minute Platelet 220
FBS 100
LIPID PANEL Thyroid Panel
Cholesterol total 150 mg/dL TSH 1.2 uIU/mL
Triglyceride 60 mg/dL
HDL cholesterol 30 mg/dL Diabetic panel
LDL cholesterol 85 mg/dL HA1C 6.8%
CARDIAC Average glucose 150
Troponin I < 0.1 ng/mL
ECG: Sinus tachycardia; T wave inversion leads I, avL, V1-3; no ST segment elevation, no Q waves.
Allergies: No known allergies
Home Med List
Drug: Generic Dose Route Indication
Aspirin 81 mg daily oral ASCVD prophylaxis
Atorvastatin 20 mg daily oral Hypercholesterolemia
Ferrous sulfate 324 mg daily oral Iron deficiency anemia
Hydrochlorothiazide 25 mg daily oral Hypertension
Metformin 1000 mg twice a day Oral Diabetes mellitus type 2
Nifedipine SR 30 mg daily oral Hypertension
- What condition is this patient experiencing: stable angina or acute coronary syndrome? If ACS, is she experiencing unstable angina, non-ST segment elevation myocardial infarction, or ST segment elevation myocardial infarction? Provide rationale.
- Provide evidence for each of the following:
a. Increased myocardial oxygen demand:
b. Decreased myocardial oxygen supply:
The patient is prescribed sublingual nitroglycerine 0.3 mg repeat x 1 and oral aspirin 325 mg dose x 1. Her pain resolves and the ECG normalizes. - Match the medicine with the correct instructions by the nurse. There is only one correct instruction for each pill.
Medicine Instruction
Nitroglycerine 0.3 mg SL Swallow this pill whole. Take it with a glass of water.
Aspirin 325 my oral I’d like you to put this pill inside your mouth and next to your cheek. Let it sit there until it dissolve.
I’d like you to put this on top of your tongue, let it dissolve, and then swallow it.
I’d like you to put this under your tongue and let is dissolve. Do not swallow it. - Nitroglycerin relaxes vascular smooth muscle via dephosphorylation of myosin (see text figure 54.2). Its pain-relieving effect occurs because it dilates veins -> reduces venous return -> reduces preload -> reduces contractility (whew!). Based on this fact, does nitroglycerine increase myocardial oxygen supply or reduce myocardial oxygen demand? Explain your reasoning.
- Aspirin in once daily doses is used for its antiplatelet effect in patients with ASCVD. ASCVD is a disease of ___ (arteries or veins). Vessels with atherosclerotic plaque trigger platelet accumulation either due to turbulent blood flow or plaque rupture (see text fig 53.2). By preventing platelets from accumulating, aspirin works by increasing myocardial oxygen supply or reducing myocardial oxygen demand? Explain your reasoning.
- Aspirin irreversibly binds to platelets. What’s the clinical significance of this finding?
Current vital signs and pertinent updates:
97.6-110-24-130/72-99%
The provider adds metoprolol 25 mg SR tablets take once a day. - Oral pills are often modified by the pharmaceutical industry for a particular purpose. I’ve listed three common modifications. Match the modification to the correct statement.
Enteric coated aspirin The pill contains spheres that contain the drug. The individual spheres dissolve at variable rates – some slowly and others more quickly – meaning the drug is released throughout the day. Sustained release formulations are used to reduce the number of pills needed per day. Dissolving these pills in water before administering them destroys the modification with the patient getting a 24-hour dose at one point.
Sustained release metoprolol This formulation is used when a patient is experiencing an acute event and needs immediate treatment.
Immediate release morphine Coated with a waxy substance to a. protect the stomach from drugs that cause discomfort and b. protect the drug from exposure to stomach acid and pepsin. Dissolving these pills destroys the modification. - The patient’s blood pressure was 130/72, yet the provider ordered metoprolol. Circle the answer that completes the blanks.
Metoprolol is an _ (adrenergic/cholinergic) (agonist/antagonist). Metoprolol is specific for _ (alpha/beta1, beta2) receptors. In this situation, metoprolol will lower blood pressure (though not a first line drug for this purpose) and lower _.
Circle the set of vital signs that indicate that metoprolol is working to reduce myocardial oxygen demand? Provide an explanation.
98.4-76-128/74-95%
98.4-110-136/84-99%
98.4-100-122/82-95%
The patient symptoms recur (diaphoresis, indigestion, nausea, and chest discomfort) now with ST segment elevation and troponin I of 2.3 ng/mL. She is transferred to the Cardiac Intensive Care Unit for management of acute coronary syndrome: ST segment elevation myocardial infarction. (SIDE BAR: In most settings a patient such as this would be sent to the Cardiac Catheterization Laboratory for a percutaneous angioplasty intervention (PCI) and stent. However, because this is a pharmacology class, we’ll focus on medication management.)
Medication Orders
Drug Dose Route Indication
Alteplase (tissue Plasminogen Activator) 100 mg over 1.5 hours. 15 mg bolus over 1-2 minutes, then infuse 50 mg/30 minute, then infuse 35 mg/1 hour. IV ACS: STEMI
Heparin 60 units per kilogram bolus, 12 units/kg/hour infusion. Titrate to aPTT 50-70 seconds. IV ACS: STEMI
Nitroglycerin 5-10 mcg/minute titrate for pain relief. Hold if SBP drops below 90 or by more than 30 mmHg. IV Acute cardiac ischemia
Think about alteplase and heparin when looking at the image below. Keep in mind that the goal is to degrade the coronary artery thrombosis and prevent its reformation. For every physiologic process there is an opposing process and that’s certainly the case with clot degradation and formation. Heparin prevents thrombosis (clot) formation by inactivating activated clotting factors. Alteplase causes clot degradation (lysis) by activating plasminogen. - First, let’s have some fun with math! The patient weighs 176 pounds. Use dimensional analysis to solve each calculation to the tenth place and do not round.
Here’s the order for heparin: Give an IV bolus of 60 units/kg followed by an infusion of 12 units/kg/hour. Titrate to aPTT 50-70 seconds.
Calculate the bolus for heparin in mLs using the vial label. The answer is 4.8 mLs. Notice I solved to the tenth place and did not round. A question very similar to this will be on the exam!
Calculate the infusion of heparin in mLs/hour using the premixed bag label. The answer is 19.2 mLs/hour. Notice I solved to the tenth place and did not round. A question very similar to this will be on the exam!
- The patient has received her alteplase, and thanks to you, also her heparin. She is now pain free and the ST segment elevation has normalized. Consider each of the following hypotheticals and respond to each question.
Alteplase has a thrombolytic duration of action of ~ one hour after completion of the infusion. There is an order for placement of a peripheral intravenous catheter 15 minutes after completion of the infusion. How should the nurse proceed?
The patient develops acute confusion and declining neurologic function. What complication has occurred?
Four hours after the alteplase and with the heparin infusing the aPTT returns with a value of 110. How should the nurse respond? What about if the value was 30? - Heparin, an anticoagulant (emphasis not an antiplatelet or a thrombolytic), has many indications but is either given subcutaneously or by bolus/continuous infusion. Think though these indications and determine which administration route is likely. Provide your reasoning.
Condition Route (bolus/infusion or SC) Reasoning
Acute cerebrovascular accident
Acute pulmonary embolus
Deep vein thrombosis
Deep vein thrombosis prophylaxis
The following adjustments were made to the patient’s medications: HCTZ and nifedipine stopped, metoprolol and nitroglycerine (in two different formulations) continued, enalapril added.
Drug: Generic Dose Route/schedule Indication
Aspirin 325 mg daily Oral/AM ASCVD prophylaxis
Atorvastatin 80 mg daily Oral/PM Hypercholesterolemia
Enalapril 20 mg daily Oral/AM Hypertension, at risk for HF (stage A)
Ferrous sulfate 324 mg daily Oral AM Iron deficiency anemia
Hydrochlorothiazide 25 mg daily Oral Hypertension
Isosorbide dinitrate 40 mg twice a day, none after 8 PM. Oral/AM & PM Angina prevention
Metformin 1000 mg twice a day Oral AM & PM Diabetes mellitus type 2
Metoprolol ER 25 mg daily Oral/AM Angina prevention
Nifedipine LA 30 mg daily Oral Hypertension
Nitroglycerin 0.3 mg prn Sublingual Angina treatment
Her morning assessment includes the following:
She is pain free and her physical exam is unremarkable. Vital signs: 99.4-82-20-140/76-95% (RA).
Labs: Place arrows up/down for values that are outside the range of normal and interpret the results.
BMP
Na 138 mOsm/L
K 5.2 mOsm/L
Cl 98
CO2 24
BUN 15
Creatinine 1.4
eGFR 43 mLs/minute
FBS 100
CLOTTING
aPTT 75
- Let’s talk about enalapril. Complete the blank spaces by circling the correct answer in parentheses. Enalapril is a(n) ___ (BB, CCN, ACEi, ARB). Its beneficial effects are caused by blocking the vasoconstricting effects of ___ (angiotensin 2, aldosterone) and blocking sodium/water reabsorption and potassium excretion effects of __ (angiotensin 2, aldosterone). Based on this, we would reliably predict that enalapril will result in which of the following (circle one of each pair): Lower BP or Raise BP, Lower blood volume or Raise blood volume, Lower potassium or Raise potassium.
- All medicines are administered. At noon her vital signs are: 98.6-64-16-120/64-94% (on room air) and she has no complaints. Explain how these vital signs are an improvement on the prior set. Don’t recite the numbers, rather explain the physiology principles.
She is scheduled for discharge the following day and follow-up with cardiac rehabilitation. Her morning assessment includes the following:
Vital signs: 99.4-60-20-124/72-95% (on room air)
Labs: Place arrows up/down for values that are outside the range of normal and interpret the results.
BMP
Na 138 mOsm/L
K 5.4 mOsm/L
Cl 98
CO2 24
BUN 15
Creatinine 1.4
eGFR 43 mLs/minute
FBS 100
CLOTTING
aPTT 30 (heparin discontinued)
Wading through a lot of clinical information can be challenging, to say the least. Let’s focus on trends over 24 hours and link each to one or more of the following drugs: enalapril, isosorbide dinitrate, metoprolol
HR: 82 – 64 – 60 If you could pick only one drug, which would be responsible for lowering her heart rate?
BP: 140/76 – 120/64 – 124/72 If you could pick only one drug as a first line antihypertensive, which would it be?
K: 5.2 – 5.4 If you could pick only one drug, which would be responsible for increasing her potassium?
Absence of chest pain. If you could pick only one drug, which would be responsible for her absence of CP?
The dose of enalapril is decreased and the patient is scheduled for afternoon discharge with the following diagnoses: HTN; ASCVD; hypercholesterolemia, Diabetes mellitus type 2; Acute myocardial infarction, renal insufficiency.
Pick one of the drugs in this case. Record yourself telling the patient about the drug using plain language (6th grade). Make sure to address why the patient is getting the drug (indication for this patient), what benefit the patient will experience, and instructions about how to take it. Here’s an example.
“Aspirin is a commonly used medicine. You’re getting it to protect your heart from developing a blood clot. You should swallow it whole and take it with food. That way it won’t bother your stomach.”
Unfolding Case Study Part Three: The Same Patient with Heart Failure and Atrial Fibrillation
Pathophysiology Concepts:
Heart failure reduced (left ventricular) ejection fraction. Treatment is threefold:
reduce symptoms of fluid volume excess (reduce preload),
make it easier for the heart to contract (reduce afterload),
delay disease progression.
A common complication of heart failure is atrial fibrillation. The atria (upper chambers of the heart quiver rather than contract).
Pharmacology for heart failure is directed at reducing preload (furosemide), reducing afterload (antihypertensives), and delaying disease progression (ACE or ARB, sacubitril/valsartan).
Pharmacology for atrial fibrillation in the context of heart failure is directed at increasing the force of myocardial contraction and decreasing heart rate (digoxin).
Case Presentation
The patient is now 62 years old. She is experiencing worsening shortness of breath, cannot walk more than a block without getting fatigued, has gained weight, and her shoes are tight. The provider advises the patient to go to the Emergency Department. In the ED she sits in a high fowler’s position and is laboring to breath.
Vital signs in 15-minute intervals with most recent first.
98.6-72-24-148/88-92% (on 2L/minute nasal cannula); 184#
97.6-100-28-144/86 (RA) – 89% (on room air); 184#
98.4-102-18-156/86 (RA) – 89% (on room air); 184#
History:
Medical: HTN; ASCVD; hypercholesterolemia, Diabetes mellitus type 2; myocardial infarction, renal insufficiency.
Surgical: NA
Social: Lives with spouse; does not smoke, drinks occasionally.
Family: Mother deceased, COD stroke; father deceased, COD heart attack; sister alive, renal insufficiency.
Home medicines: No known allergies
Drug: Generic Dose Route/schedule Indication
Aspirin 325 mg daily Oral/AM ASCVD prophylaxis
Atorvastatin 80 mg daily Oral/PM Hypercholesterolemia
Enalapril 20 mg daily Oral/AM Hypertension, at risk for HF (stage A)
Ferrous sulfate 324 mg daily Oral AM Iron deficiency anemia
Hydrochlorothiazide 25 mg daily Oral Hypertension
Isosorbide dinitrate 40 mg twice a day, none after 8 PM. Oral/AM & PM Angina
Metformin 1000 mg twice a day Oral AM & PM Diabetes mellitus type 2
Metoprolol ER 25 mg daily Oral/AM Angina
Nitroglycerin 0.3 mg prn Sublingual Angina
Labs: Place arrows up/down for values that are outside the range of normal.
BMP CBC
Na 140 mOsm/L WBC 9.0
K 5.6 mOsm/L RBC 4
Cl 100 Hemoglobin 12
CO2 24 Hematocrit 36
BUN 18 MCV 92
Creatinine 1.6 MCHC 34
eGFR 35 mLs/minute Platelet 220
FBS 100
LIPID PANEL Thyroid Panel
Cholesterol total 150 mg/dL TSH 1.2 uIU/mL
Triglyceride 60 mg/dL
HDL cholesterol 30 mg/dL Diabetic panel
LDL cholesterol 85 mg/dL HA1C 6.7%
CARDIAC Average glucose 143
Troponin I < 0.1 ng/mL Natriuretic peptide (BNP) (nl<125; HF > 900) 2000 pg/mL
The normal troponin means she hasn’t had a heart attack, the elevated BNP means she has heart failure.
ECG: Sinus rhythm, widened QRS, tented T waves. No ST segment elevation/Q waves (confirming she is not experiencing an acute ischemic event).
- The ECG findings of a widened QRS complex and tented T wave are consistent with which lab abnormality (circle one): sodium, potassium, creatinine, troponin, BNP?
Draw a picture of the electrocardiographic effect of increased serum potassium. Here’s a normal electrocardiographic rhythm and a blank for the artist in the group!
Draw normal Ps, widened QRS, and tented Ts. Those are the hallmarks of electrocardiographic hyperkalemia.
CXR: See side panel.
Echocardiogram: Dilated cardiac silhouette (see XRAY above),
thin ventricular walls, enlarged left ventricular chambers, and an
ejection fraction of 20% (EF = SV/EDV) (SV = stroke volume,
EDV = end diastolic volume).
In the Emergency Department the patient receives 20 mg of
furosemide by intravenous push and she diuresis 1500 mLs of
dilute urine. She receives a low dose of intravenous morphine sulfate
(reduces preload and relieves air hunger).
Provide three reasons that furosemide was selected over the home medicine, hydrochlorothiazide.Heart failure reduced ejection fraction is characterized by cardiac
remodeling (thinning and fibrosis of muscle and enlarged chamber)
with reduced ejection fraction. Compensatory responses to
decreased cardiac output generally make the failing heart work
harder which generally worsens its decline.
Pharmacotherapy for HFrEF is directed at decreasing the work of
the failing heart and preventing remodeling.
Complete the table below using your knowledge of pharmacology! Compensatory responses Drugs used to disrupt mechanism
Sympathetic nervous system activation
Activation of RAA system leading to cardiac remodeling (dilation, thinning, fibrosis)
Fluid retention and increased blood volume
And notice that the drugs you so wisely entered above coincide with the recommendations from the ACC/AHA and the NYHA!
The next morning the patient’s assessment is as follows:
Vital signs: 98.6-72-18-122/76-96% (on 2L/minute nasal cannula); 178#
Physical exam:
Constitutional: Appears comfortable;
Heart/PV: Skin warm/dry, pulses 1+, lower extremity edema 1+ to mid-calf, nl S1, S2, +S3, II/VI systolic murmur left sternal border
Pulm: Sitting up right, one pillow orthopnea throughout night, upper lobes clear anterior/posterior, crackles right and left lower lobes.
Labs: Place arrows up/down for values that are outside the range of normal and interpret the results.
BMP
Na 140 mOsm/L
K 5.0 mOsm/L
Cl 100
CO2 24
BUN 18
Creatinine 1.3
eGFR 52 mLs/minute
FBS 115
CARDIAC
Natriuretic peptide (BNP) 1000 pg/mL
Here are her medications. Notice the indications have expanded. This is an important concept. Drugs and indications are not static.
Drug: Generic Dose Route/schedule Indication
Atorvastatin 80 mg daily Oral/PM Hypercholesterolemia
Aspirin 325 mg daily Oral/AM ASCVD prophylaxis
Enalapril 20 mg daily Oral/AM Hypertension, HF (stage C)
Ferrous sulfate 324 mg daily Oral AM Iron deficiency anemia
Hydrochlorothiazide 25 mg daily Oral Hypertension, HF (stage C)
Isosorbide dinitrate 40 mg twice a day, none after 8 PM. Oral/AM & PM Angina
Metformin 1000 mg twice a day Oral AM & PM Diabetes mellitus type 2
Metoprolol ER 25 mg daily Oral/AM Angina, HF (stage C)
Nitroglycerin 0.3 mg prn Sublingual Angina
The patient is doing well, and the nurse is preparing for her discharge the following day. One additional medication has been added. Entresto 49/51. Entresto is a combination of sacubitril and valsartan.
- The nurse should clarify this order because Entresto contains a drug, _____, that is very similar in mechanism to the drug, _________, which she is already receiving.
- Sacubitril, one of the two drugs in Entresto, works to increase the natriuretic peptide response to heart failure. This is beneficial because the natriuretic response: place up/down arrow or complete the word.
_ diuresis vasoconstriction
vasodilation _ fibrosis
The patient is discharged on the following medications. Please note medication reconciliation
Drug: Generic Dose Route/schedule Indication
Aspirin 325 mg daily Oral/AM ASCVD prophylaxis
Atorvastatin 80 mg daily Oral/PM Hypercholesterolemia
Enalapril 20 mg daily Oral/AM Hypertension, HF (stage C)
Ferrous sulfate 324 mg daily Oral AM Iron deficiency anemia
Hydrochlorothiazide 25 mg daily Oral Hypertension, HF (stage C)
Isosorbide dinitrate 40 mg twice a day, none after 8 PM. Oral/AM & PM Angina
Metformin 1000 mg twice a day Oral AM & PM Diabetes mellitus type 2
Metoprolol ER 25 mg daily Oral/AM Angina, HF (stage C)
Nitroglycerin 0.3 mg prn Sublingual Angina
Sacubitril/Valsartan 49/51 mg Daily HF (stage C)
The patient follows up at her primary care clinic three days after discharge. She is still short of breath though not as severely as prior to her admission. The nurse takes her vital signs and does a brief physical exam:
Vital signs: 98.6; 105 (Irregular); 18; 90/60 sitting & 120/72 supine; SpO2 95%; 178#.
History and Physical exam:
Lightheaded when sitting/standing suddenly; senses heart “flopping” in chest; tired of being sick all the time; sleeps with two pillows
Constitutional: Appears tired
Heart/PV: Skin warm/dry, pulses 1+ and irregular, lower extremity edema 1+ to mid-calf, nl S1, S2, II/VI systolic murmur left sternal border
Pulm: Crackles posterior lower lobes right/left
The ECG shows atrial fibrillation, a common complication of heart failure that occurs in response to stretching of the atria.
The patient is referred to the hospital but declines admission because she would prefer to be treated at home. The following adjustments are made to her medications:
Drug: Generic Dose Route/schedule Indication
Atorvastatin 80 mg daily Oral/PM Hypercholesterolemia
Aspirin 325 mg daily Oral/AM ASCVD prophylaxis
Digoxin 0.125 mg Oral/AM Atrial fibrillation/HF
Ferrous sulfate 324 mg daily Oral AM Iron deficiency anemia
Hydrochlorothiazide 50 mg daily Oral Hypertension, HF (stage C)
Isosorbide dinitrate 40 mg twice a day, none after 8 PM. Oral/AM & PM Angina
Metformin 1000 mg twice a day Oral AM & PM Diabetes mellitus type 2
Metoprolol ER 25 mg daily Oral/AM Angina, HF (stage C)
Nitroglycerin 0.3 mg prn Sublingual Angina
Sacubitril/Valsartan 49/51 mg 24/26 mg Daily HF (stage C)
- Answer each of the following:
What are the two indications for digoxin for this patient?
What is the likely rationale for discontinuing the isosorbide dinitrate?
What is the likely rationale for decreasing the sacubitril/valsartan?
The mechanisms by which digoxin works are complicated, to say the least. Here is how it works to increase inotropy (look it up if you’re not certain of its meaning).
The mechanism for decreased chronotropy is even more challenging so just memorize this for now: digoxin decreases heart rate by increased vagal nerve stimulation (CN X originates in the CNS and provides parasympathetic stimulation to the heart (i.e. slows it)) and by slowing conduction through the AV node. Okay, if that’s more physiology than you care to deal with, just know it slows heart rate.
Digoxin is rarely used first line because it has a narrow therapeutic index and therapeutic range and requires very careful monitoring.
- What is the mathematical concept of narrow therapeutic index versus a wide therapeutic index? Draw and image.
- What is the mathematical concept of narrow therapeutic range? Draw an image.
Monitoring for digoxin effectiveness and toxicity is an essential part of nursing practice because it is a dangerous drug. This patient is getting digoxin to slow the heart rate in atrial fibrillation and to increase inotropy for her heart failure.
Before administering digoxin, the nurse must make sure there are no indications of accumulation or toxicity. - Complete the following table.
Helpful Blood Work Warning values Rationale for checking
Digoxin level
K
BUN/Cr
Helpful Cardiac Findings
Heart rate
Helpful non-cardiac findings
Gastrointestinal
Visual - The nurse is instructing the patient about the expected effects of digoxin. Match the nursing instruction to digoxin’s mechanism.
Instruction Digoxin mechanism
I’d like you to check your heart rate in the morning. Do this placing your fingers on the inside of your wrist just below the thumb. Count your pulse there. It should be b/n 60 – 100 per minute Positive inotropy
If you notice you are losing strength in your arms and legs, please give us a call because we are probably going to have to do some lab tests. Negative chronotropic effect
It’s important for you to get out and walk. I’d like you to walk for at least 5-10 minutes every day without getting tired. Hypokalemia
Summary:
This unfolding case study emphasizes the pharmacology for a hypothetical patient who experiences hypertension and atherosclerosis that progresses to ischemic heart disease/acute coronary syndrome that progresses to heart failure reduced ejection fraction. The emphasis has been on pharmacologic therapy. However, for each condition the nurse should also be aware of non-pharmacologic interventions such as exercise, weight control, and healthy diet.
Although not a major emphasis in the case, it’s important to realize that her predisposition and then development of diabetes mellitus accelerates her ASCVD. Further, her iron deficiency anemia, which is essentially unaddressed, would be particularly problematic during her acute coronary syndrome/ST segment elevation myocardial infarction because her oxygen delivery would be negatively affected because her capacity would be low.
The order of events presented here is not uncommon but keep in mind that not all patients with hypertension/atherosclerosis experience an STEMI and not all STEMIs lead to heart failure. These critical, life- changing events may occur independently on one another.
Finally, people of different genders and races and socioeconomic status have different profiles. For example,
premenopausal women experience an atherosclerotic benefit that disappears after menopause and estrogen decline;
child-bearing women should avoid drugs that are passed to the fetus and have known teratogenicity: ACEs, ARBs, and warfarin come to mind;
African Americans benefit more from diuretics and CCB than other antihypertensive;
Medication reconciliation is needed at every transition of care;
Drugs cost money – and usually the newer the drug the more costly it is. Here’s data from GoodRx for some of the drugs for cardiovascular disease:
Drug GoodRx Cost
Entresto (combo valsartan and sacubitril) ~ 500/60 pills
Valsartan ~ 25/60 pills
Metoprolol ER ~ 20/60 pills
Enalapril ~22/60 pills
Metoprolol ~5/60 pills
Apixaban ~444/60
Warfarin ~8/60
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