Disease discussion

What is the disease all about?

● CHF is a complex clinical syndrome that results from any

structural or functional impairment of ventricular filling
or ejection of blood.
● Cardinal manifestations: dyspnea, fatigue, and fluid
retention which may lead to pulmonary/peripheral edema
● The most severe manifestation of CHF, pulmonary
edema, develops when an imbalance causes an increase
in lung fluid secondary to leakage from pulmonary
capillaries into the interstitium and alveoli of the lung.
Disease discussion
Etiology and Pathophysiology
→Congestive heart failure due to high blood pressure, aortic or
mitral valve disease, or cardiomyopathy is a common cause of pulmonary
edema (creates a backup of pressure in the small blood vessels of the
lungs, which causes the vessels to leak fluid)

→ inability to provide adequate cardiac output

→ structural abnormalities (congenital or acquired) that affect the

peripheral and coronary arterial circulation, pericardium, myocardium, or
cardiac valves, thus leading to increased hemodynamic burden or
myocardial or coronary insufficiency

→ an increased hemodynamic burden or a reduction in oxygen

delivery to the myocardium results in impairment of myocardial
contraction

→ may be precipitated by progression of the underlying heart

disease

→ results from a decline in stroke volume that is due to systolic

dysfunction, diastolic dysfunction, or a combination of the two
Disease Discussion

Staging and Prognosis

Disease Discussion

Staging and Prognosis

● prognosis for CHF varies greatly between people, as there are many different factors that
contribute to what an individual’s prognosis might be.
● If discovered in its earlier stages and is properly managed= better prognosis than if
discovered much later.
● Some people whose CHF is discovered early and treated promptly and effectively can hope
to have a nearly normal life expectancy.
● According to the Centers for Disease Control and Prevention (CDC), around half of people
diagnosed with CHF will survive beyond five years.
Disease Discussion

Risk Factors

· High blood pressure · Alcohol use

· Coronary artery disease · Tobacco use

· Heart attack · Obesity

· Diabetes · Irregular heartbeats

· Sleep apnea · Valvular heart disease

· Congenital heart defects · Viruses

· ·
Disease Discussion

Signs and Symptoms

Symptoms you may notice first Symptoms that indicate your Symptoms that indicate a severe
condition has worsened heart condition

fatigue irregular heartbeat Chest pain that radiates

through the upper body

swelling in your ankles, feet, a cought that develops from rapid breathing
and legs congested lungs

weight gain wheezing skin that appears blue, which

is due to lack of oxygen in
your lung

increased need to urinate, shortness of breath, which fainting

especially at night may indicate pulmonary
edema
Disease Discussion
Diagnosis and Detection

- review symptoms and perform a physical examination

- check for the presence of risk factors, such as high blood pressure,
coronary artery disease or diabetes
- lungs for signs of congestion (abnormal heart sounds that may
suggest heart failure)
- examine the veins in the neck and check for fluid buildup in the
abdomen and legs

After physical exam, the doctor may require these ff tests:

- blood tests
- chest x-ray
- ECG
- Echocardiogram
- Stress test
- CT scan
- MRI
- Coronary Angiogram
- Myocardial biopsy
 Patient E.L.V.
● Age: 79 y.o.
● Sex: Male
● Weight: 61 kg
● Room 0001, Surgical Intensive Care Unit
History of Present Illness:

● One day prior to admission, patient

experienced hypoglycemia and
dizziness.
● Few hours prior to admission, the
patient had difficulty breathing and
an occlusive cough.
Past Medical History:
● Angioplasty (1997)
● Pacemaker Insertion (1997)
● Automatic Implantable Cardioverter
Defibrillator (1997)
● PCI (2007)
● Below the Knee Amputation [R] (2007)
Social History:
● Smoker
Patient details
Ancillary Services:
Laboratory Services
Laboratory Services
Continuation
 Patient details
Review of Systems:
Cardiovascular
●Congestive heart failure (CHF)
●Cardiovascular artery disease (CAD)
●Hypertensive atherosclerotic cardiovascular disease (HACD)
●Peripheral artery occlusive disease (PAOD)
Endocrine
●Diabetes mellitus Type 2
●Amiodarone-induced hypothyroidism
Excretory
●Chronic Kidney Disease secondary to Diabetes Mellitus
Type 2
Course in the Wards
Lab results

Laboratory Test Patient’s Normal Interpretation

Values Range

TSH (Thyroid 19.8 mlU/L 0.3-3.04 Increased TSH

Stimulating mIU/L
Hormone)

FT3 (Free 1.54 pg/mL 2.3-4.2 pg/mL Decreased TSH

triiodothyronine)
Course in the Wards
Lab results

Laboratory Test Patient’s Normal Interpretation

Values Range

Hb (Hemoglobin) 9.4 g/dL 13.8-17.2 g/dL Decreased Hb

Hct (Hematocrit) 29.3% 41-50% Decreased Hct

3.2 mil/uL 4.4-5.8 mil/uL Decreased RBC

RBC (Red blood

cell)
Course in the Wards
Lab results

Laboratory Test Patient’s Normal Range Interpretation

Values

UA (Uric acid) 9.2 mg/dL 4.0-8.5 mg/dL Increased UA

serum

Fructosamine 293.56 200-285 Increased

micromol/L micromol/L fructosamine

Glycohemoglobin 6.8% 6.5% Slightly

increased
Course in the Wards
Lab results
Ancillary

INTERPRETATION:

Day 4 (6/19) - CBG

monitoring showed patient
had hyperglycemia and
suddenly increased to 304
mg/dL. Lantus was
increased to 40 units and
patient was given a rescue
dose of 10 units.Novorapid
was increased to 10 units
pre-meals and held sliding
scale.
Day 5 (6/20) - CBG was slowly stabilizing. Novorapid was
decreased to 6 units pre-meals and Lantus to 30 units.
Day 6 (6/21) – CBG was slightly below normal. Lantus and
Novorapid was put on hold.
Day 7 (6/22) – CBG slightly above normal. Novorapid sliding
scale was continued.
Problem List

● Diabetes
● Hypokalemia
● Pulmonary Edema
● Anemia
● Difficulty of breathing
● Occlusive Cough
● Difficulty in sleeping
● CKD
 Goals

1. Treat Pulmonary Edema

2. Eliminate or control underlying causes or risk factors

● Hypertension

● Atrial fibrillation secondary to CAD

● Amiodarone-induced hypothyroidism

● Diabetes

● CKD (anaemia associated with CKD)

● Discontinue tobacco use

 Goals

3. Relieve symptoms and prevent complications

● SOB
● Occlusive cough
● Difficulty in sleeping
● Muscle spasm
● Low potassium levels (hypokalemia)
● Increased serum uric acid
● infection
 List of Medications
Patient’s Own Medications
Name of Dose Route Frequency Date & Date & Remarks Indication
medication Time Time
Ordered Started

Trimetazidine 35 mg PO BID
(Vastarel)

DHA+EPA 1 cap PO BID

(Omacor)

Amiodarone 200 mg PO Once daily AF and

(Cordarone) CAD
prevention

Melatonin 3 mg PO Once daily Increased to

5 mg 1 tab
qHS

Atorvastatin 20 mg PO Once daily Secondary

(Lipitor) prevention
to CAD

Isosorbide 30 mg PO Once daily Increased to

mononitrate 60mg/tab
(Imdur) Once daily
List of Medications
Patient’s Own Medications
Name of Dose Rout Frequency Date & Date & Remarks Indication
medication e Time Time
Ordered Started

Ketoanalogue 600 mg PO TID Prevention

+ Essential x 2 tabs and treatment
amino acids of damage of
(Ketosteril) CKD

Pantoprazole 40 mg PO BID
(Pantoloc)

Acetylcysteine 1200 mg PO BID (06/16/2011) (06/16/2011) Prevention of

(Fluimucil) (SD: 600 (06/21/2011) (06/21/2011) CI-
mg) Nephropathy

Levothyroxine 100mcg PO Once daily hypothyroidis

(Eltroxin) M-F, m
50mcg
Sat-Sun

Epoetin alfa 4000 SQ 2x/wk Th &

(Eprex) units Saturdays
List of Medications
Patient’s Own Medications
Name of Dose Route Frequency Date & Date & Remarks Indication
medication Time Time
Ordered Started

Clopidogrel 75 mg PO 4 tabs (06/16/2011) (06/17/2011) Was on Coronary

(Plavix) tonight, then hold then Artery
1 tab in AM resumed Disease
due to
blood
extraction

Pentoxifyllin 400 mg PO BID (06/16/2011) (06/17/2011) Was on Intermitten

e (Trental) hold then t
resumed Claudicati
due to on
blood
extraction

CoQ10 30 mg PO BID

Iberet Folic PO Once daily

List of Medications
Standing Medications
Name of Dose Route Frequency Date & Date & Remarks Indication
medication Time Time
Ordered Started

Bumetanide 1 mg IV Q12 Pulmonar

(Burinex) y edema

Ampicillin 500 mg IV Q6 06/20/2011 06/20/2011 Infection

Potassium 10 PO 1 tab TID x 5 06/20/2011 06/20/2011 Hypokale

Chloride mEqs doses mia
(Kalium
Durules)

Amlodipine 5 mg PO Once daily 06/21/2011 06/21/2011 Hypertens

besylate ion
(Norvasc)

Pregabalin 50 mg PO BID 06/22/2011 06/22/2011 Muscle

(Lyrica) spasm or
twitching

Vitamin C 500 mg PO BID 06/22/2011 06/22/2011

List of Medications
Standing Medications
Name of Dose Route Frequency Date & Date & Remarks Indication
medication Time Time
Ordered Started

Paracetamol 325 mg/ PO BID-RTC

+ Tramadol 37.5 mg
(Dolcet)

Hydralazine 25 mg PO TID 06/16/2011 06/16/201 Hypertens

1 ion

Aspirin 80 mg PO 2 tabs
(Aspilet) tonight & 1
tab in AM

Allopurinol 100 mg PO Once Daily 06/17/2011 06/17/201 Hyperuric

(Purinase) 1 emia
List of Medications
PRN Medications
Name of Dose Route Frequency Date & Date & Remarks Indication
medication Time Time
Ordered Started

Clonazepam ¼ tab PO 06/17/2011 06/17/201 give ¼ tab for

(Rivotril) If unable 1 at 8pm If unable seizures,
SD: 2 mg to sleep to sleep panic
attacks

Paracetamol 325 mg/ PO BID-RTC

+ Tramadol 37.5 mg
(Dolcet)
List of Medications
Stat Medications
Name of Dose Route Frequency Date & Date & Remarks Indication
medication Time Time
Ordered Started

Isosorbide 30 mg PO
mononitrate
(Imdur)

Alprazolam 50 mcg/ PO Difficulty

(Xanor) tab in
sleeping

Lactulose

Pregabalin 50 mg PO BID 06/22/2011 06/22/201 For

(Lyrica) 1 muscle
spasms

Diphenhydra 50 mg PO
mine
(Benadryl)

Diazepam 5 mg PO
(Valium)
List of Medications
IV Fluids
Name of Dose Route Frequency Date & Date & Remarks Indication
medication Time Time
Ordered Started

D5W 1L *KVO Once NPO

List of Medications
Insulin
Name of Dose Route Frequency Date & Date & Remarks Indication
medication Time Time
Ordered Started

Insulin Pre-meals CBG 94-

Aspart 169, 103-
(Novorapid) 167

Sliding scale
160-200 3 units SQ
201-250 5 units SQ
251-300 8 units SQ
>300 10 units SQ
<60 1 vial D5050
61-90 ½ vial D5050
Pharmacotherapy Goals
 Guidelines vs. Actual Management
Pulmonary Edema

Actual Treatment Guidelines

Day 1 Furosemide 40mg IV GUIDELINES ✓

- Diuretics are indicated for patients with evidence of
fluid overload. Give 40 mg furosemide IV.
SOURCE: Managing Acute Pulmonary Oedema, Australian
Bumetanide (Burinex) Prescriber Vol. 40: No.2: April 2017
1mg IV push for I/O
<50mL/hr and revised GUIDELINES ✓
to <30mL/hr - Use of diuretics for patients with HF to relieve
Day 3 Bumetanide (Burinex) 1 breathlessness and edema in patients with symptoms
mg IV and signs of congestion.
- Loop diuretics - Bumetanide: starting dose 0.5-1.0 mg,
usual dose 1-5 mg
SOURCE: 2016 ESC Guidelines for the diagnosis and
treatment of acute and chronic HF
 Hypertension

Actual Treatment Guidelines

Day 1 BP 175/100 GUIDELINES ⤬

Hydralazine 25mg po bid
Trimetazidine (Vastarel) 35mg
po od
Isosorbide mononitrate (Imdur) - Lisinopril 10-40 mg, captopril 12.5-150 mg
30 mg po od
Day 6 Amlodipine Besylate (Norvasc)
5mg od
- In adults with CKD present with or without
Diabetes, the BP goal is <140/90
- Treatment of choice is ACEI/ARB
- Losartan 50-100 mg, telmisartan 20-80 mg
- For many other common antihypertensive
agents, including alpha blockers, beta
blockers, and calcium channel blockers,
limited data exist to guide the choice of
antihypertensive therapy

GUIDELINES:
JNC 8 HTN GUIDELINES, 2017 HIGH BLOOD
PRESSURE CLINICAL PRACTICE GUIDELINE
 AF secondary to CAD

Actual Treatment Guidelines

Day 1 Amiodarone GUIDELINES ✓

(Cordarone) 200 mg - Amiodarone is an effective multichannel blocker, reduces
PO od co- ventricular rate, and is safe in patients with heart failure
administered with - Torsades de pointes pro-arrhythmia can occur, and QT
Atorvastatin (Lipitor) interval and TU waves should be monitored on therapy
20 mg po od as - Amiodarone as a long-term rhythm control therapy for
secondary patients with AF and reduces mortality in patients with
prevention for CAD CAD
- Atorvastatin is safe and effective for preventing and
treating CAD regardless of cholesterol levels.

GUIDELINES:
2016 ESC Guidelines for the management of atrial fibrillation
developed in collaboration with EACT. Role of Statins in CAD,
Chonnam Medical Journal. Amiodarone Inhibits Arterial
Thrombus Formation and Tissue Factor Translation,
 Hypothyroidism

Actual Treatment Guidelines

Day 1 TSH: 19.8 GUIDELINES ✓

amiodarone induced - Patients above 10mIU/L should be treated
hypothyroidism - Levothyroxine/ L-thyroxine monotherapy has become
Levothyroxine the mainstay of treating hypothyroidism
(Eltroxin) 100 mcg 2 - Doses of 25-75 µg daily are usually sufficient for
achieving euthyroid levels but larger doses are usually
tabs M-F; 50 mcg
required for those presenting with higher TSH values.
Sat-Sun od - Take it with water between 30 and 60 minutes prior to
eating breakfast

GUIDELINES:
CLINICAL PRACTICE GUIDELINES FOR HYPOTHYROIDISM IN
ADULTS 2012
 Hypokalemia

Actual Treatment Guidelines

Day 1 Slightly low K levels GUIDELINES ✓

(3.3) - Goal of treatment is the prevention of potentially life-
Potassium chloride threatening cardiac conduction disturbances and
(Kalium Durules) 10 neuromuscular dysfunction by raising serum potassium to a
mEqs/tab 1 tab tid x 6 safe level
- Patients with a history of congestive heart failure or
doses
myocardial infarction should maintain a serum potassium
concentration of at least 4 mEq per L
Day 5 Low K = 3.2
- Rapid correction is possible with oral potassium
Potassium chloride - Nonurgent hypokalemia is treated with 40 to 100 mmol of
(Kalium Durules) 1 tab oral potassium per day over days to weeks
tid x 5 doses started
SOURCE: Potassium Disorders: Hypokalemia and Hyperkalemia,
American Association of Family Physicians. Management of
Hypokalemia, World Association of Sustainable Development
 Anemia

Actual Treatment Guidelines

Day 1 Hg: 9.4g/dL —anemia associated

with CKD
Epoetine alfa (Eprex) 4000 units
2x/wk SQ dose based on weight
(61 kg)
 Hypoglycemia/Hyperglycemia

Actual Treatment Guidelines

Day 1 Stat: 1 vial D5050

Insulin Aspart (Novorapid)
CBG 140-180 3 units SQ
GUIDELINES ⤬
181-220 4 units SQ
221-260 6 units SQ
-according to The Hospital Management of Hypoglycemia in
Adults with Diabetes Mellitus by the Joint British Societies
Day 2 Hyperglycemia (CBG:126-206; Fructosamine 293.59)
Insulin Glargine (Lantus) 10 units SQ every 9am started and Diabetes UK, adults who have a blood glucose level of
Insulin Aspart (Novorapid) 3 units SQ pre-meals also started
CBG 180-220 add 2 units SQ greater than 4.0 mmol/L (72.073 mg/dL) should be treated
221-260 add 3 units SQ
261-300 add 5 units SQ
with a small carbohydrate snack only such as 1 medium
>300 add 7 units SQ banana, slice of bread, or normal meal if due.

Day 3 CBG 285 mg/dL

Insulin Glargine (Lantus) increased to 30 units every 0900H

Day 4 Fluctuating CBG (126-206-156-153-144-302-285-165-232)

Insulin Glargine (Lantus) increased to 40 units every 0900H and 10 units at
1800H as rescue dose
Pre meals: Aspart (Novorapid) 3 units SQ pre-meals increased to 10 units
SQ

Day 5 Stable CBG (168-167/187-67/114)

Insulin Aspart (Novorapid) 10 units SQ pre-meals decreased to 6 units
Insulin Glargine (Lantus) decreased to 30 units

Day 6 Stable CBG (87-67-114-94-54-105)

On Hold: Insulin Aspart (Novorapid) and Insulin Glargine (Lantus)

Day 7 (CBG 94-169, 103-167)

Continued: Insulin Aspart (Novorapid) CBG 160-200 -> 3units
201-250 -> 5units
251-300 -> 8units
>300 -> 10 units
Get CBG after 4 hrs once NPO
If hypogly: Give 1 vial D5050 if CBG <60 ½ vial D5050 if CBG 61-90
If hypergly: Use Novorapid scale above
 SOB

Actual Treatment Guidelines

Day 1 Isosorbide mononitrate (Imdur) NONPHARMACOLOGIC

30 mg tab ● Oxygen therapy is the standard of care for patients
with dyspnea, the ACCP determined that
supplemental oxygen can provide relief for patients
with dyspnea who are hypoxemic at rest or during
minimal activity.
● Pursed-lip breathing, a breathing strategy often
used by patients with airway obstruction, can
provide relief of dyspnea. When performed at rest,
pursed-lip breathing improves oxygen saturation,
reduces carbon dioxide levels, and promotes slower,
deeper breathing
● Noninvasive positive pressure ventilation can
provide some relief. Three systematic reviews of
noninvasive positive pressure ventilation concluded
that it improved the patient’s perception of
dyspnea.
 SOB

Actual Treatment Guidelines

Day 1 Isosorbide mononitrate (Imdur) PHARMACOLOGIC

30 mg tab ● Oral and parenteral opioids can improve
dyspnea. Morphine may be a promising
treatment for the relief of air hunger, the
most typical variant of dyspnea

SOURCE:
Graham, L. (2010). Practice Guidelines:
ACCP Releases Statement on Dyspnea
Treatment in Patients with Advanced Lung or
Heart Disease. Am Fam Physician. 2010 Oct
15;82(8):999-1000.
 Sleeping

Actual Treatment Guidelines

Day 1 Stat: Alprazolam (Xanor) 250 In the presence of co-morbidities, clinical

mcg/tab judgement should decide whether insomnia or
the co-morbid condition is treated first, or
whether both are treated at the same time.
Day 2 Clonazepam (Rivotril) 1/4 tab at
CBT-I is recommended as first-line treatment for
8pm
chronic insomnia in adults of any age
SD: 2 mg/tab was given.
A pharmacological intervention can be offered if
May still give 1/4 tab at 12 mn if
CBT-I is not effective or not available.
still unable to sleep
BZ and BZRA are effective in the short-term
Melatonin 3mg/cap 1 cap then
treatment of insomnia (≤4 weeks; high-quality
increased to 5 mg 1 tab qHS
evidence).

Actual Treatment
Day 1 Stat: Alprazolam (Xanor) 250
mcg/tab
Day 2 Clonazepam (Rivotril) 1/4 tab at
8pm
SD: 2 mg/tab was given.
May still give 1/4 tab at 12 mn if
still unable to sleep
Melatonin 3mg/cap 1 cap then
increased to 5 mg 1 tab qHS
Sleeping
Guidelines
• The newer BZRA are equally effective as BZ
(moderate-quality evidence).
• BZ/BZRA with shorter half-lives may have less
side-effects concerning sedation in the morning
(moderate-quality evidence).
• Long-term treatment of insomnia with BZ or
BZRA is not generally recommended.
• Sedating antidepressants are effective in the
short-term treatment of insomnia; Long-term
treatment of insomnia with sedating
antidepressants is not generally recommended

Actual Treatment
Day 1 Stat: Alprazolam (Xanor) 250
mcg/tab
Day 2 Clonazepam (Rivotril) 1/4 tab at
8pm
SD: 2 mg/tab was given.
May still give 1/4 tab at 12 mn if
still unable to sleep
Melatonin 3mg/cap 1 cap then
increased to 5 mg 1 tab qHS
Sleeping
Guidelines
Antipsychotics
• Because of insufficient evidence and in light of
their side-effects, antipsychotics are not
recommended for insomnia treatment (strong
recommendation, very low-quality evidence).
• Melatonin is not generally recommended for
the treatment of insomnia because of low
efficacy (weak recommendation, low-quality
evidence).
SOURCE:
Riemann, D., Baglioni, C., Bassetti, C. et al,
European guideline for the diagnosis and
treatment of insomnia. J Sleep Res. 2017;:675–
700.
 Uric Acid

Actual Treatment Guidelines

Day 2 Uric acid: 9.2 Guideline: 2012 American College of

Allopurinol 100 mg/tab od Rheumatology Guidelines for Management of
Stat: Lactulose Gout
● recommendation of XOI therapy with either
allopurinol or febuxostat as the first-line
pharmacologic approach
● serum urate level (target 6 mg/dl at a
minimum, and often 5 mg/dl)
● starting dosage of allopurinol should be no
greater than 100 mg/day and less than that
in moderate to severe chronic kidney disease
(CKD), followed by gradual upward titration
of the maintenance dose, which can exceed
300 mg daily even in patients with CKD

Actual Treatment
Day 5 Infection: Bacteria = 178
WBC = 154
Linezolid 600 mg q12 shifted to
Ampicillin 500 mg IV q6
Infection
Guidelines
Sepsis in Adults - Source Unclear:
Preferred Regimen:
1st Line:
Piperacillin-tazobactam 4.5g IV q6-8h PLUS
Vancomycin 25-30mg/kg loading dose then 1g IV
q8h
2nd Line:
Meropenem 1g IV q8h PLUS Vancomycin 25-
30mg/kg loading dose then 1g IV q8h
SOURCE:
National Antibiotic Guidelines, DOH, 2017
 Muscle Spasm
Actual Treatment
Day 7 Muscle spasm/twitching from
post-op site to thigh
Stat: Pregabalin (Lyrica) 50 mg po
bid
Guidelines
Guidelines: ⤬
There were no mentions of the use of Pregabalin
in the management of a patient’s muscle spasm
but there were other Level C evidence based
recommendations that suggest the use of
Naftidrofuryl, diltiazem, and vitamin
B complex for the treatment
of the patient’s muscle cramps.
Source: American Academy of Neurology (2010).
Assessment: Symptomatic treatment for muscle
cramps (an evidence-based review)

Actual Treatment
Day 1 Prevention & therapy of damage
due to patient’s CKD
Ketoanalogue + Essential Amino
acids (Ketosteril) 600 mg 2 tabs
TID
CKD
Guidelines
Guidelines: ⤬
The guidelines suggest avoiding high protein
intake (41.3 g/kg/day) in adults with CKD at risk
of progression, however this evidence is still not
widely tested on different races and there are no
specific recommendations that suggest the
intake of ketoanalogue + essential amino acids to
compensate for the deficiency of nutritional
protein in CKD patients.
Source: KDIGO 2012 Clinical Practice Guideline
for the Evaluation and Management of
Chronic Kidney Disease
 Blood

Actual Treatment Guidelines

Day 1 On Hold for blood extraction: Guideline: /

Clopidogrel (plavix) 75 mg po od
Pentoxifylline (trantal) 400 mg Haemolysis, contamination, and presence of
po bid intravenous fluid and medication can all alter the
Cavedilol (Dilatrend) results.
Insulin Glargine (Lantus)
Day 2 Resumed after blood extraction Source: WHO Guidelines on Drawing Blood: Best
Clopidogrel (Plavix) 75 mg PO od Practices in Phlebotomy, 2010
Pentoxifylline (Trental) 400 mg
po BID
Day 7 Clopidogrel (Plavix) 75mg 4 tabs
at night then 1 tab in AM
started: Vit C 500 mg 2 tabs bid
 Blood Glucose
Actual Treatment Guidelines
Day 5 ●Laboratory results showed Guideline:
stable CBG (168-167/187-
67/114). Insulin Aspart
(Novorapid) 10 units SQ pre-
meals was decreased to 6 units
pre-meals. (HOLD: if CBG is ≤ 90
mg/dL). Insulin Glargine
(Lantus) was decreased to 30
units.
Day 6 ●Laboratory result showed
stable CBG (87-67,-114-94-54-
105) Insulin Aspart (Novorapid) Source: Guidelines on Inpatient
and Insulin Glargine (Lantus) Management of Hyperglycemia
was on hold.
 Blood glucose

Actual Treatment Guidelines

Day 7 (CBG 94-169, 103-167) continue Insulin Guidelines:

Aspart (Novorapid)
CBG
160-200 -> 3units
201-250 -> 5units
251-300 -> 8units
>300 -> 10 units
Get CBG after 4 hrs once NPO
If hypogly: Give 1 vial D5050 if CBG <60
½ vial D5050 if CBG 61-90
If hypergly: Use Novorapid scale above
 Other therapy

Actual Treatment Guidelines

Day 1 Patient is to undergo CT Scan or Guideline: X

MRI — was given to prevent N-Acetylcysteine (NAC) was previously advocated
contrast-induced nephropathy. to reduce the incidence of CIN, however there is
increasing evidence suggesting it is not
Acetylcysteine (Fluimucil) 600 efficacious in preventing CIN. Its use is not
mg 2 tabs in 50 mL water BID therefore considered necessary, but based on its
ease of use and lack of side effects centres may
opt to add it to a renal protection protocol.

Day 6 Acetylcysteine (Fluimucil) Source: Consensus Guidelines for the Prevention of

increased to 1200 mg bid Contrast Induced Nephropathy, June 2011
(SD:600mg)
Recommendations and Intervention
Subjective
● Difficulty of breathing
● Chest X-ray showed acute pulmonary edema secondary to CHF
● One day PTA experienced hypoglycemia & dizziness
● Few hours PTA difficulty of breathing & occlusive cough
● CHF, CAD, HACD, PAOD, DM type 2, amiodarone-induced hypothyroidism,
CKD secondary to DM type 2
Objective
Age 79

Weight 61 kg

BP 175/100

TSH (Thyroid Stimulating Hormone) 19.8 mIU/L (0.3 - 3.04 mIU/L)

FT3 (Free triiodothyronine) 1.54 pg/mL (2.3 - 4.2 pg/mL)

Hemoglobin 9.4 g/dL (13.8 - 17.2 g/dL)

Hematocrit 29.3% (41 - 50%)

Red Blood Cell 3.2 mil/uL (4.4 - 5.8 mil/uL)

UA (Uric Acid) 9.2 mg/dL (4.0 - 8.5 mg/dL)

Fructosamine 293.56 μmol/L (200 - 285 μmol/L)

Glycohemoglobin 6.8% (6.5%)

Assessment
● More effective drug available - Hydralazine 25mg po bid, Trimetazidine
(Vastarel) 35mg po od, Isosorbide mononitrate (Imdur) 30 mg po od was
administered for hypertension but guidelines state that in adults with CKD
with or without Diabetes, treatment of choice is ACEI/ARB. ARB does not
exacerbate cough.
● Avoidable ADR - Amiodarone-induced hypothyroidism. Lowering the dose of
amiodarone can prevent the progression of hypothyroidism
● No indication - Pantoprazole (Pantoloc). There was no diagnosis of GERD or
ulceration.
● Pulmonary edema most likely caused the shortness of breath of the patient,
which in turn made sleeping difficult for the patient.
Assessment
DRUG INTERACTION

● Amiodarone will increase the level or effect of Atorvastatin by P-Glycoprotein efflux

transporter.
● Alprazolam with Diazepam or Clonazepam may increase sedation.
● Melatonin increases effects of Clopidogrel by anticoagulation.
● Aspirin increases and Bumetanide decreases serum potassium.
● Ampicillin and Aspirin either increases levels of the other by plasma protein binding
competition.
Plan
● Discontinue Hydralazine, Trimetazidine (Vastarel), and Isosorbide
mononitrate (Imdur). Recommend giving an angiotensin II receptor blocker
for treatment of hypertension. Losartan 50-100 mg
● For the shortness of breath, proceed with oxygen therapy as the standard of
care for patients with dyspnea according to the guideline.
● Monitor potassium levels.
● Lower the dose of amiodarone to 100mg.
● Suggest to physician to order for a renal function test (SCr and BUN) to
determine the stage of CKD.
● Discontinue Pantoprazole.
● To address the sleeping problem and muscle spasm, maintain diazepam.
● Discontinue melatonin, alprazolam, and clonazepam previously given for the
sleeping difficulty.
● Discontinue pregabalin since according to the guideline, there is no mention
of it for the management of muscle spasm.
● Continue epoetin alfa to address patient’s anemia.
Plan
Management of Pulmonary edema

1. Secure ABC (Airway, Breathing, Circulation)

2. Oxygen
3. Diet - Low Salt to minimize fluid retention
4. Preload Reduction - NTG and Loop Diuretic (Furosemide)
5. Afterload Reduction - ARBs
Patient Counseling

Smoking cessation - talk to the doctor about strategies and

programs to help break the smoking habit.

Eat a healthy diet that is low in salt, sugar and solid fats
and rich in fruits, vegetables and whole grains.

Maintain a healthy weight.

Patient Counseling

-Do not crush or chew the tablet

- If you miss a dose, take it as soon as possible with your

regular schedule. If it is almost time for your next dose, skip
the missed dose and continue with your regular dosing
schedule. Do not take a double dose to make up for a missed
one.

-Contact your doctor if the side effects you experience are

severe and troublesome.
References

2013 ACCF/AHA Guideline for the Management of Heart Failure: Executive Summary

Grossman, S. (2004). Current Thinking In Acute Congestive Heart Failure And

Pulmonary Edema. US Cardiology. Retrieved from https://www.uscjournal.com/ on
May 14, 2018

Brindles Lee Macon and Kristeen Cherney (2018) Congestive Heart Failure .
Retrieved from https://www.healthline.com/health/congestive-heart-
failure#symptoms

Mayo Foundation for Medical Education and Research (2017). Heart Failure. [online]
Mayoclinic.org. Available at: https://www.mayoclinic.org/diseases-conditions/heart-
failure/symptoms-causes/syc-20373142 [Accessed 15 May 2018]
References
Kirchhof, P., Benussi, S., Kotecha, D., Ahlsson, A., Atar, D., Casadei, B., . . . Zeppenfeld, K. (2016). 2016
ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. European
Heart Journal,37(38), 2893-2962. doi:10.1093/eurheartj/ehw210

Lim, S. Y. (2013). Role of Statins in Coronary Artery Disease. Chonnam Medical Journal, 49(1), 1–6.
http://doi.org/10.4068/cmj.2013.49.1.1

Breitenstein, A., Stampfli, S., Camici, G., Akhmedov, A., Ha, H., Follath, F., . . . Tanner, F. (2008).
Amiodarone Inhibits Arterial Thrombus Formation and Tissue Factor Translation. Arteriosclerosis,
Thrombosis, and Vascular Biology,28(12), 2231-2238. doi:10.1161/atvbaha.108.171272

Garber, J., Cobin, R., Gharib, H., Hennessey, J., Klein, I., Mechanick, J., . . . Woeber, K. (2012). Clinical
Practice Guidelines for Hypothyroidism in Adults: Cosponsored by the American Association of Clinical
Endocrinologists and the American Thyroid Association. Endocrine Practice,18(6), 988-1028.
doi:10.4158/ep12280.gl

Viera, A. J., & Wouk, N. (2015, September 15). Potassium Disorders: Hypokalemia and Hyperkalemia.
Retrieved from https://www.aafp.org/afp/2015/0915/p487.html

Eltoum, M., & World Association for Sustainable Development. (2017, March 26). ABC of Intravenous
Fluids, Electrolyte Disorders and AKI - Management of Hypokalemia. Retrieved from
http://www.wasd.org.uk/wp-content/uploads/2017/03/C05-Hypokalaemia.pdf