Ischemic heart disease

Case Report
Undersupervision of Dr. Mahmoud samaha

Prepared by: Dina Mohamed – Ragaa Ali – Donia Waleed – Rahma Fakhry – Rahma Mohamed – Rowaida Ebrahim – Reem Mohamed
– Reem Essam – Rofaida Mohamed – Rudaina Ahmed – Rania Waleed – Rehab Akmal - Raed Abdullah – Ramla Omar
 Introduction
Ischemic heart disease: lack of oxygen and decreased or no blood flow to the myocardium resulting
from coronary artery narrowing or obstruction .
Acute coronary syndrome:It is a clinical presentation often accompanied by acute chest pain or other
myocardial damage markers and changes on ECG due to impaired blood flow of heart muscle.
Ischemic heart disease and acute coronary syndrome are both related to the inadequate supply of and
oxygen to the heart muscle.
 CLINICAL PICTURE
there are many symptoms of ischemic heart disease and acute choronary syndrome
including:
1. Chest pain, especially after physical exertion.
2. Dizziness or fainting.
3. Heart palpitations, which may feel like your heart
fluttering or skipping beats.
4. Shortness of breath.
 Chief Complaint

“I don’t think the drugs are working for my chest

pain.”
History of Present Illness(HPI)
David Lassee is a 67-year-old man with coronary artery disease.
He has had two coronary artery bypass operations. He has been
seen on several occasions recently because of frequent angina. A
coronary angiogram performed 1 month ago revealed significant
disease in the RCA proximal to his graft, but this was considered
high risk for angioplasty. His dose of isosorbide mononitrate was
increased at that time from 60 mg to 120 mg once daily. This had
no effect on his angina. He is still using approximately 30
nitroglycerin tablets a week, and these do relieve his chest pain.
He reports that most often the chest discomfort comes on with
activity, such as walking. The dis- comfort is located in the center
of his chest and rated as a 3–4 out of 10 on average. He reports that
the chest discomfort slowly fades as he slows his activity. He
also complains of occasional lightheadedness, with a pulse of
around 50 beats per minute and SBP near 100 mm Hg.
 Past Medical History
• Acute anterior wall MI with CABG in 1976
• Posterior lateral MI in 1990 and PTCA to the circumflex at that
time Redo
• CABG in 1998
• Ischemic cardiomyopathy
• Heart failure with an ejection fraction of 40%
• Dyslipidemia
• COPD (mild)
• Chronic low back pain
• Depression
 Family History
Noncontributory for premature coronary artery disease

Risk Factors For this Patient

I. Age (67)
II. Sex ( man)
III. previous smoker
IV. drinks occasionally
Social History V. Dyslipidemia
VI. Heart failure
Retired dairy farmer; lives with wife; VII. two coronary artery bypass operations
drinks occasionally; previous smoker
,quit in 1998
 Medications

● Carvedilol 6.25 mg twice daily

● Lisinopril 5 mg once daily
● Furosemide 40 mg once daily
● Aspirin 325 mg once daily
● Isosorbide mononitrate 120 mg once
daily
● Diltiazem extended-release 240 mg once
daily
● Escitalopram 20 mg once daily
● Celecoxib 200 mg once daily
● Atorvastatin 20 mg once daily
● Nitroglycerin 0.4 mg SL PRN
 Comment
Isosorbide mononitrate

● Chronic long-acting nitrates have not been shown to reduce CHD events after MI and
are not used in ACS patients who have undergone revascularization
Diltiazem
● Calcium channel blockers is contraindicated as the PMH shows that he suffered a
myocardial infarction and have concomitant left ventricular dysfunction.

Atorvastatin 20mg

● It shows ineffective drud therapy as the dose is too low for his condition
 Review of system(ROS)

No fever, chills, or night sweats. No recent viral illnesses.

No shortness of breath; occasional cough with cold weather No
nausea, vomiting, diarrhea, constipation , melena, or
hematochezia. No dysuria or hematuria. No myalgias or arthralgias.

This mean , the patient is healthy without any alarming

symptoms.
Physical Examination
Gen
cooperative man
VS
BP 105/68, P 50, RR 22, T 36.4°C
Skin
Intact, no rashes or ulcers
Neck
Supple, no masses; no JVD, lymphadenopathy, or thyromegaly
Lungs
Bilateral air entry is clear. No wheezes.
CV
normal, no murmurs or gallops
Genit/Rect
Heme (-) stool
Neuro
A & Ox 3, CNs II-XII intact; speech is fluent, no motor or sensory deficit; no facial asymmetry;
tongue midline
 LABs

From Labs results there are:

1) an increase in triglycerides and cholesterol levels.

2) a decrease in HDL than the normal range.
3) That indicated to Hyperlipidemia which is the main cause of atherosclerosis and it
may lead to other cardiovascular diseases .
 ECG Assessment

Sinus rhythm Heart Rate : • Old man

50beats Bradycardia
• Uncontrolled angina
ST-T wave :
Normal • multiple medications who is a poor
candidate for angioplasty
QT/QTc :
406/431
Questions
 Problem identification
What drug-related problems appear to be present in this patient?
1. Lightheadedness
2. Nitrate tolerance
3. Bradycardia

Could any of these problems potentially be caused or exacer- bated by

his current therapy?
Lightheadedness: Maybe Caused by Isosorbide Mononitrates and Nitroglycerin
Isosorbide

Bradycardia: Caused by Carvedilol and Diltiazem

Dry cough: May Increased by Taking Lisinopril

 Desired outcome

What are the goals of pharmacotherapy for IHD

in this case?

• Elimination of angina chest pain and return to normal

activities.

• To slow progression of atherosclerosis and prevent

complications such as myocardial infarction (MI), heart failure,
stroke, and death.
 Therapeutic alternative
Does this patient possess any modifiable risk factors for IHD?
1. Dyslipidemia
2. Obesity
What pharmacotherapeutic options are available for treating this patient's IHD?
HD? Discuss the agents in each class with respect to their relative usefulness in his
care.
• To reduce risk of graft closure: • Ranolazin • High_intenisty Statins:
Aspirin It reduces ischemic episodes and For lipid lowering therapy
• Long_Acting Nitrates: improves myocardial function
• ACE inhibitors:
As he is contraindicated to b_blocker and Perfusion and taken as As he has left ventricular
because of Bradycardia monotherapy to relieve angina
dysfunction (ejection
symptoms .
fraction 40%)
 Optimal Plan
Given the patient information provided, construct a complete
pharmacotherapeutic plan for optimizing management of his IHD.
• Given pharmacotherapeutic plan is necessary to optimize management of ischemic heart disease (IHD). The plan should
aim to control symptoms, prevent further cardiac events, and address comorbidities.

1.Anti-Anginal Therapy: 3.Anticoagulation:

- Amlodipine:10 mg once daily Enoxaparin: 1 mg/kg subcutaneously every 12 hours

- Ranolazine:500 mg twice daily (fora maximum of 8 days or until PCI)

2. Nitroglycerin 4.Antiplatelet Therapy:

Continue nitroglycerin sublingual - Clopidogrel:75 mg once daily (after initial loading

as needed foracute episodes of chest dose)
pain - Aspirin: 325 mg once daily (continue for secondary
prevention)
5. Glycoprotein IIb/IIIa Inhibitor:
- Eptifibatide: 180 mcg/kg bolus followed by 2 mcg/kg/min
9.HeartFailure Management:
infusion (during PCI)
-Furosemide: Continue currentdose as needed
6. Statin Therapy: forheart failure symptoms.
- Atorvastatin: 40 mg once daily (continue forlipid
management)
10. Depression Management:
- Escitalopram: Continue the current dose of 20 mg once
7.Beta-Blocker Therapy: daily.
- Metoprolol or Atenolol :50 mg once daily
11. Pain Management:
8. ACE InhibitorTherapy: - Celecoxib: Discontinue celecoxib due to its potential
adverse cardiovascular effects
- Lisinopril: Continue current dose unless contraindicated.
12. Patient Education:
- Educate the patient on the importance of medication adherence and lifestyle modifications to optimize hearthealth.
- Provide guidance on recognizing and responding to symptoms of acute coronary syndrome.
- Encourage regular follow-up appointments with the cardiologist forongoing management and monitoring.

13. Monitoring:
- Monitor the patient's symptoms, blood pressure, heart rate,and cardiac enzymes closely.
- Follow up with the patientafter PCI to assess stent patency and adjusttherapyas needed.

14. Referral:
- Consider referralto cardiac rehabilitationprogram for structured exercise training and lifestyle modification
counseling post-PCI.
 Late Hospitalization/Secondary prevention
● Dual Antiplatlet Therapy [Aspirin +Clopidogril]
● Asprin 81mg indefinitely
● Clopidogrel for at least 12 months

● Lisinopril indefinitely

● High intensity statin: Atorvastatin 80 mg

● Add aldosterone antagonists: Eplerenone 25mg once daily

● Furosemide 40 mg
● SL NTG 0.4 mg PRN
● Escitalopram 20 mg once daily
● Celecoxib 200 mg once daily
 Out come evaluation
When the patient returns to the clinic in 2 weeks for a follow-up
visit, how will you evaluate the response to his new antianginal
regiment for efficacy and adverse effecta!
New Antianginal Regimen Evaluation Steps
• Symptom Assessment: Regularly monitor patient’s anginal symptoms using standardized scales like the
Canadian Cardiovascular Society grading of angina pectoris.
• Functional Testing: Perform exercise stress testing to evaluate exercise capacity and assess changes
in exercise-induced symptoms or ischemia.
• Adverse Effect Monitoring: Monitor potential adverse effects of the antianginal medications,
including hypotension, bradycardia, and other cardiovascular and non-cardiovascular side effects.
• Patient Feedback: Engage the patient in discussions about their experience with the new
regimen and encourage prompt reporting of new symptoms or concerns.
• Imaging Studies: Consider cardiac imaging studies like echocardiography or ECG to
assess changes in myocardial perfusion or function.
 Patient Education
What information will you communicate to the patient about his
antianginal regimen to help him experience the greatest benefit and
fewest adverse effects?

● Medication understanding
● Highlight the positive outcomes
● Emphasize that adherence to the prescribed regimen is
crucial.
● Discuss potential side effect
● Encourage patients to report any unusual symptoms promptly.
● Reinforce healthy habits
● Schedule regular follow-up visits to assess progress.
● Address any concerns or questions the patient may have.

Medication Understanding
 Aspirin These help prevent blood
clots and maintain stent patency.
 Atorvastatin (say to the patient
it is the blue one if there is
nothing like it in the meds )They
lower cholesterol levels and
reduce cardiovascular risk.
 Metoprolol These control heart
rate and reduce angina
symptoms.
 Lisinopril Used for blood
pressure control and potential
heart protection.
Cont.
Adverse Effects Awareness
• Headache, Dizziness, and
Fatigue
• Low Blood Pressure
(Hypotension): Especially
when standing up.
• Slow Heart Rate
(Bradycardia): Relevant for
beta-blockers.
• Hyperkalemia
Lifestyle modification
Stress Management: Stress
can worsen angina; explore
relaxation techniques.
Diet: Encourage a heart-
healthy diet (low in saturated
fats and salt).
Follow-Up Plan
Tell the patient to Visit or
calling the pharmacist for any
questions about the meds and
your situation
 Clinical course
Mr. Lasser improved hemodynamically after a witch from diltia zem to amlodipine. However, because
of continued frequent epi- sodes of angina, his amlodipine was titrated to 10 mg once daily. He returns
to cardiology clinic today, stating that his angina frequency has improved somewhat on the maximum
dose of amlodipine but is still bothersome to him. His cardiologist decided to add ranola zine 500 mg
twice daily to his regimen in an attempt to further decrease his angina frequency. Two months later, the
patient’s cardiologist is notified of his arrival at the ED of a regional hospital. The patient is
complaining of severe substernal chest pain that came on at rest. He rated the pain as 10 out of 10 on
presentation and said that it radiated to his left arm. He has received only partial relief with IV NTG
and morphine. An ECG revealed 1-mm ST-segment depression in the inferior leads consis tent with
inferior wall ischemia. A troponin level was drawn but is not yet available for interpretation. He is
diagnosed with acute coronary syndrome, and his cardiologist has requested that he be given
clopidogrel 600 mg orally x 1, enoxaparin 90 mg subcutane- ously x 1, and eptifibatide 180 mcg/kg
bolus followed by 2 mcg/kg/ min and transferred for cardiac catheterization. On arrival, angiog raphy
revealed a high-grade lesion with thrombus in the RCA proximal to his graft. Despite the high risk of
the procedure, the decision was made to perform percutaneous coronary intervention (PCI), with
deployment of a 3.5-mm CYPHER sirolimus-eluting coronary stent.
 Cont.

• The patient took diltazem which is CCB which directly affect on

blood vessels.

• But when replaced by Amplodipine that is non CCB That directly

affect on heat and it was effective for angina and angina was
improved.

• But doctor decided to add Ranolazine as patient was still bother some
to patient and it decreases angina frequency.
 Follow-up questions

What is the recommended duration of dual-antiplatelet therapy with

aspirin plus clopidogrel in the setting of percutancous coronary
intervention with drug-cluting stents?
It based on the type of stent and patient factors. However, a common duration recommended is:

• At least 12 months of dual-antiplatelet therapy (DAPT) for patients receiving DES to reduce the
risk of stent thrombosis.

• After the initial 12 months, decisions about continuing antiplatelet therapy should be individualized
based on the patient's overall ischemic and bleeding risks.

• It's essential to adhere to the prescribed duration of DAPT to maximize the benefits of
preventing stent thrombosis while minimizing the risk of bleeding complications.
 Cont.

What data support antithrombotic therapy with bivalirudin alone as an

alternative to the combination of enoxaparin plus eptifib- atide in this
patient?

EUROMAX Trial:

This trial evaluated bivalirudin versus heparin plus GPI in patients with STEMI undergoing
primary PCI.
It showed that bivalirudin reduced the risk of major bleeding without increasing the risk of
adverse ischemic events compared to heparin plus GPI.
Thank you