Posted: June 1st, 2023

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  Read a selection of your colleagues’ responses and respond to at least two of your colleagues on two different days who were assigned a different patient case study, and provide recommendations for alternative drug treatments to address the patient’s pathophysiology. Be specific and provide examples. 

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Knowing how to diagnose and treat complex patient illnesses is important to understand as an advanced practice provider.  The case study provided this week is about a 66 year old women with a history of MI, HTN, Hyperlipidemia, and diabetes mellitus who presents with sudden onset of diaphoresis, nausea, vomiting, dyspnea, followed by a bandlike upper chest pain that she rates 8/10 and radiates down her left arm.  With the health history and her current symptoms, I am immediately worried about another cardiac event for this patient.  This patient has many risk factors for cardiac events. Not only does she have previous heart history, she has HTN, Hyperlipidemia and Diabetes, all of which increase her risk for cardiac events significantly. Brewer et al. (2015) state that the number of men and women who are affected by and die from CAD outnumber all other conditions including all forms of cancer in the US.  Women present differently when having cardiac events.  Brewer et al. (2015), points out that there is significant evidence that adverse outcomes in women with IHD may be fueled by underestimation of cardiovascular disease risk, leading to underdiagnosis and undertreatment.
Due to the acute presentation of this patient, treating her quickly to prevent further heart damage is imperative. An EKG needs to be done within 10 minutes of the patients’ arrival to review for ST elevation and blood sent to lab to evaluate cardiac enzymes.  Oxygen would be my first medication intervention.  The patient complains of dyspnea and chest pain with radiation on a scale of 8/10.  Anytime there is pain we assume there is damage being done to the heart.  Oxygen will help with the dyspnea and provide extra oxygen to the tissues in the heart and hopefully prevent damage.  ASA 4 chewable 81mg tablets would also need to be administered to this patient.  Aspirin suppresses platelet aggregation, producing an immediate antithrombotic effect.  It has been identified as causing a substantial reduction in mortality.
Morphine to treat the pain is the treatment of choice in acute STEMI situations.  In addition to treating the pain, it improves hemodynamics by promoting venodilation and reducing cardiac preload.  It can also reduce modest arterial dilation and in so reduce afterload as well.  This reduction in preload and afterload help by lowering cardiac oxygen demand, helping to preserve the ischemic myocardium.  Beta blockers are also important in treating acute STEMI. The reduce cardiac pain, infarct size, and short-term mortality.  They also reduce recurrent ischemia and reinfarction.  They reduce myocardial wall tension and may decrease the risk for myocardial rupture. Continued use of oral beta-blockers increases long term survival rates.  They work by blocking preventing beta receptor activation.  Ultimately this reduces heart rate and contractibility, reducing oxygen demands and blood pressure. They increase coronary blood flow and myocardial oxygen supply.  This patient is already taking Metoprolol 50mg BID at home so this step has already been taken.
The patient’s cardiac enzymes are positive which verifies an acute cardiac event.  The rest of her labs and vital signs are normal. My next drug of choice would be nitroglycerin, which according to Rosenthal et al. (2018), acts directly on vascular smooth muscle to promote vasodilation.  This works by increasing the blood flow to the ischemic areas of the heart.  Educating the patient that this medication cause headache, orthostatic hypotension, and reflex tachycardia are important, along with the benefits of this medication for her current condition.  Nitroglycerin should be avoided in patients with hypotension, bradycardia, and suspected right ventricular infection.
I work in a small critical access hospital so at this point I would be contacting a tertiary care center for cardiology recommendations and transfer of cares for this patient.  Sometimes the cardiologist will recommend reperfusion therapy with fibrinolytics prior to transfer for PCI therapy.  Fibrinolytic drugs resolve clots by converting plasminogen into plasmin, a proteolytic enzyme that digests the fibrin meshwork that holds a clot together.  The common drugs used for this is alteplase, reteplase, and tenecteplase.  These drugs are most effective when presentation is early.  When given in a timely manner they can open the occluded artery in 80% of patients.  The major complications of this therapy are bleeding, which occurs in 1-5% of patients.  Intercranial hemorrhage is the greatest concern.  Patients undergo an intense screening process to make sure they are appropriate candidates for therapy and reduce the risk of these complications.  Patients who receive this therapy are also treated with anticoagulants such as heparin and antiplatelets such as aspirin or Plavix.  These are proven to decrease mortality in acute cardiac events.
The patient at this time is ready to be transferred to a cardiac unit for further evaluation and treatment by a cardiologist.  Making sure the patient is educated and understands each treatment and why it is important along with the risks is an important part of treating acute cardiac events.  It is a scary time for the patient and knowing what is going on can help to ease anxiety and fears.

   
                                                References
Anderson, J. L., & Morrow, D. A. (2017). Acute Myocardial Infarction. The New England Journal of Medicine. doi: 10.1056/NEJMral606915
Brewer, L. C., Svatikova, A., & Mulvagh, S. L. (2015). The Challenges of Prevention, Diagnosis and Treatment of Ischemic Heart Disease in Women. Cardiovascular Drugs and Therapy, 29(4), 355–368. doi: 10.1007/s10557-015-6607-4
Rosenthal, L. D., & Burchum, J. R. (2018). Lehne’s pharmacotherapeutics for advanced practice providers. St. Louis, MO: Elsevier.

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