Case study 1 reply:
Evaluating this case study, we need to identify the stage of the disease in order to address the treatment. In this case study, in my opinion, patient is in stage C of heart failure because patient is currently having symptoms of this disease and he had known structural heart disease (previous IMA). He has shortness of breath on exertion that relieves with rest, reduced exercise tolerance, and orthopnea. Besides, another important factors in the management of the disease, in this particular case, is the Hypertension, previous surgery (stent placement), dyslipidemia, and echocardiogram with decreased Ejection Fraction (Bonow, Ganiats, Beam, et al., 2012).
In this case, the management of the disease, according to ACCF/AHA guidelines includes lifestyle modifications, like obesity, tobacco use, alcohol consumption, controlling amount of salt on diet, among others. Hypertension and lipid disorders should be controlled, too. Medications involves diuretics, ACE inhibitors, Beta blockers, Digitalis, and dietary sodium restriction (1500mg/day) (Clyde, Casey, Drazner, et al., 2013).
Diuretics are used in treating HTN, fluid retention, and improving dyspnea symptoms. Thiazide diuretics is used in initial therapy for overload. Hydrochlorothiazide at initial dose of 25 mg daily. Loop diuretics are preferred for decompensation. Furosemide is the first choice, in dose of 20-40 mg daily or twice daily. Thiazide diuretics should be stopped before using this treatment. Doses should be titrated.
ACE inhibitors improve symptoms, decease morbidity and increase life expectancy in all populations. It is useful as monotherapy or in combination with beta blockers. It is the drug of choice in patients with left ventricular dysfunction and in patients with Diabetes mellitus. In this case we can use Captopril beginning at 6.25 mg three times a day. (Stone, Robinson, Lichtenstein, Merz, et al., 2013).
Beta Blockers can be use in patients with history of MI, like our patient, because these drugs improve ventricular function. These medications are Carvedilol (initial dose 3.125 mg twice daily), Metoprolol (1.25 mg daily), and Bisoprolol. (Mc Murray, Adamapoulos, Anker, Auricchio, Bohm, et al., 2012)
Digoxin remains a consideration for management of Heart failure in patients with reduced ejection fraction less than 40%. It has more side effects than ACE inhibitor. Angiotensin II Receptors blockers are used as a substitute in patients that cannot use ACE inhibitors. Another options of treatment that are less used include Calcium Channel Blockers and Nitrates.
2. Does he need medication(s) given his history of MI? If yes, write a complete prescription using the prescription format previously provided.
This patient need medication due to the history of Myocardial Infarction. ACE inhibitors has been demonstrated reduce the cardiovascular mortality and the reinfarction rate in post MI patients with left ventricular dysfunction. Other medications should be beta blockers, and Angiotensin II receptor blockers. ACE inhibitors like Captopril can be used at Initial dose: 6.25 mg orally once as early as three days post-myocardial infarction, followed by 12.5 mg orally three times a day; increase to 25 mg orally three times a day over the next several days, and then increase to target dose (50 mg tid) over the next several weeks as tolerated (Mc Murray, et al., 2012).