Pharmacotherapeutic Management of Ischemic Heart Disease (IHD) in Jack Palmer

QUESTION

Jack Palmer is a 72-year-old man with coronary artery disease. He is an avid golfer and prefers to walk the course, but this is becoming progressively more difficult for him due to frequent angina. He has had two coronary artery bypass operations in the past. 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 to 120 mg once daily. This had no effect on his angina. He is still using about 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 up slight inclines on the golf course. The discomfort is located in the center of his chest and rated 3-4/10 on average. He reports that the chest discomfort slowly fades as he slows his activity. He also complains of occasional lightheadedness with a pulse around 50 bpm and SBP near 100 mm Hg.

PMH

Acute anterior wall MI with CABG surgery in 2009

Posterior lateral MI in 1990 and PTCA to the circumflex at that time

Dyslipidemia

Chronic low back pain

Depression

FH

Noncontributory for premature CAD.

SH

Retired dairy farmer, lives with wife, drinks occasionally, previous smoker—quit in 1998

Meds

Carvedilol 6.25 mg PO twice daily

Lisinopril 5 mg PO once daily

Aspirin 325 mg PO once daily

Isosorbide mononitrate, extended release 120 mg PO once daily

Diltiazem, extended release 240 mg PO once daily

St. John’s wort 300 mg PO three times daily

Celecoxib 200 mg PO once daily

Simvastatin 40 mg PO once daily

Nitroglycerin 0.4 mg SL PRN

All

NKDA

ROS

No fever, chills, or night sweats. No recent viral illnesses. No shortness of breath; occasional cough with cold weather.

1a. What drug-related problems appear to be present in this patient?

1b. Could any of these problems potentially be caused or exacerbated by his current therapy

Desired Outcome

2. What are the goals of pharmacotherapy for IHD in this case?

Therapeutic Alternatives

3a. Does this patient possess any modifiable risk factors for IHD?

3b. What pharmacotherapeutic options are available for treating this patient’s IDH? Discuss the agents in each class with respect to their relative utility in his care.

Optimal Plan

4. Given the patient information provided, construct a complete pharmacotherapeutic plan for optimizing management of his IHD.

Outcome Evaluation

5. 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 reign for efficacy and adverse effects?

Patient Education

6. What information will you  communicate to this patient about his antianginal regimen to help him experience the greatest benefit and fewest adverse effects?

ANSWER

Pharmacotherapeutic Management of Ischemic Heart Disease (IHD) in Jack Palmer

Drug-Related Problems

Several drug-related problems are apparent in Jack Palmer’s case:

Inadequate Angina Control: Frequent angina despite increased dose of isosorbide mononitrate and regular use of nitroglycerin tablets.
Lightheadedness and Bradycardia: Occasional lightheadedness associated with low pulse rate (around 50 bpm) and systolic blood pressure (SBP) near 100 mm Hg.
Polypharmacy: Taking multiple medications, some of which might interact or contribute to his symptoms.

Potential Causes or Exacerbations

His current therapy may contribute to the problems:
Isosorbide mononitrate: Despite dose increase, inadequate control of angina could suggest tolerance or less responsiveness.
Carvedilol and Diltiazem: May contribute to bradycardia and lightheadedness.

Goals of Pharmacotherapy

The goals of pharmacotherapy for Jack Palmer’s IHD are to alleviate angina symptoms, improve exercise tolerance, and enhance his quality of life while minimizing adverse effects.

Modifiable Risk Factors
Modifiable risk factors for IHD include his history of smoking and dyslipidemia.

Pharmacotherapeutic Options

Pharmacotherapeutic options to consider for treating Jack’s IHD are:

Nitrate Therapy: Considering his nitroglycerin use, sublingual nitroglycerin PRN or nitroglycerin patches could provide more consistent angina relief.
Beta-Blockers: Carvedilol is already in use, but it may contribute to bradycardia and hypotension. A possible alternative could be metoprolol succinate, which is cardioselective.
Calcium Channel Blockers: Diltiazem is contributing to bradycardia. A switch to amlodipine could be considered for vasodilation without affecting heart rate.

Optimal Pharmacotherapeutic Plan

Considering Jack’s case, a revised pharmacotherapeutic plan could be:
Nitroglycerin 0.4 mg SL PRN for acute angina episodes.
Metoprolol succinate 25 mg PO once daily for beta-blockade without excessive bradycardia.
Amlodipine 5 mg PO once daily for vasodilation.
Isosorbide mononitrate should be reevaluated for dose adjustment or discontinuation.

Outcome Evaluation

At the follow-up visit, evaluation will involve assessing his angina frequency, exercise tolerance, and adverse effects. Angina reduction, improved exercise capacity, and absence of significant adverse effects would indicate treatment success.

Patient Education

Patient education is essential to ensure optimal outcomes and minimize adverse effects. Key points to communicate include:
How to take each medication correctly.
The purpose of each medication in relieving angina and improving blood flow.
Importance of adherence to prescribed regimen.
Possible adverse effects to watch for, such as dizziness or lightheadedness.
The importance of reporting any significant changes or adverse effects promptly to the healthcare provider.

In conclusion, Jack Palmer’s case highlights the complexity of managing IHD in a geriatric patient with comorbidities. A personalized pharmacotherapeutic plan considering angina relief, exercise tolerance improvement, and minimizing adverse effects is crucial for optimizing his quality of life. Communication and patient education play a pivotal role in achieving treatment goals while ensuring patient safety and satisfaction.