Mr. EBR is a 74-year-old retired Hispanic gentleman with known coronary artery disease (CAD)
Mr. EBR is a 74-year-old retired Hispanic gentleman with known coronary artery disease (CAD), who presents to your clinic with substernal chest pain for the past 3 months. It is not positional; it reliably occurs with exertion, approximately one to two times daily, and is relieved with rest, or one or two sublingual nitroglycerin (NTG) tabs. It is similar in quality, but is much less severe, than the chest pain that occurred with his previous inferior myocardial infarction (MI) 3 years ago. Until the past 3 months, he has felt well.
The chest pain is accompanied by diaphoresis and nausea, but no shortness of breath (SOB) or palpitations. He does not vomit. He denies orthopnea, paroxysmal nocturnal dyspnea (PND), syncope, presyncope, dizziness, lightheadedness, and symptoms of stroke or transient ischemic attack (TIA). An echocardiogram done after his MI demonstrated a preserved left ventricular ejection fraction (LVEF). Other medical problems include well-controlled type 2 diabetes mellitus (DM), well-controlled hypertension (HTN), and hyperlipidemia, with low-density lipoprotein (LDL) at goal. He also has stage 3 chronic kidney disease (CKD) and diabetic neuropathy. He no longer smokes and does not use alcohol or recreational drugs. His daily medications include: Atenolol 25 mg PO bid, Lisinopril 20 mg PO bid, aspirin 81 mg PO daily, Simvastatin 80 mg PO each evening, and metformin 500 mg PO bid.
Mr. EBR’s physical examination includes the following: height 68 inches, weight 185 lb, Blood pressure (BP) 126/78, heart rate (HR) 64, Respiratory rate (RR) 16, and temperature 98.6°F orally. He is alert and oriented, and in no apparent distress (NAD). His neck is without jugular venous distention (JVD) or carotid bruits. Lungs are clear to auscultation bilaterally. Cardiovascular: normal S1 & S2, RRR, without rubs, murmurs or gallops. Abdomen has active bowel tones and is soft, nontender, and nondistended (NTND). Extremities are without clubbing, cyanosis, or edema. Distal pedal pulses are 2+ bilaterally
- What would you add to the current treatment plan? Why?
- Would you discontinue any of the currently prescribed medication? Why or why not?
- How does the diagnosis stage 3 chronic kidney disease affect your choices?
- Why is the patient prescribed more than one antihypertensive?
- What is the benefit of the aspirin therapy in this patient?
ANSWER
Coronary Artery Disease (CAD) Treatment Plan
What to Add in Current Treatment Plan
Most of Mr. EBR’s medications are functioning well. For instance, Atenolol 25 mg PO bid and Lisinopril 20 mg PO bid given to him has helped in controlling his BP and thus improving his health in terms of Hypertension. Also, his diabetes has been improved by metformin 500 mg PO bid medication. However, a painkiller and heart-related treatment are not working well. Thus, I would recommend another treatment plan for the patient to reduce the effects of coronary artery disease. I would recommend other cholesterol-modifying medications, such as and also ask the patient to conduct more exercises.
Medication to Discontinue
The only medication that I would discontinue is Simvastatin 80 mg PO. I would discontinue the medication because it is not helping the patient deal with the heart condition. Instead, I would recommend atorvastatin (Lipitor). Atorvastatin is a first-line treatment for the heart-related condition (Wang et al., 2019). I help the patient with lower cholesterol levels. I will not interfere with other medications because they show positive effects.
Effects of Stage Three Chronic Kidney on Medication
According to Bruchfeld and Lindahl (2019), stage three, CKD, is a condition where the patient’s kidney is moderately damaged. The condition might affect the nurse’s choice drugs because of the cost of drugs that treat kidney related-conditions. If provided with an expensive drug prescription, the patient might fail to all the medication. Another reason is the medications may be too many, and thus the patient might fail to take all of them. Lastly, my choice of drugs can be affected by side effects of atorvastatin and CKD drugs on the patient’s health.
Why the Patient Takes Many Antihypertensive
Antihypertensive are a group of medications used for treating high blood pressure. Healthcare professionals prescribe drugs, depending on the level of the disease. Also, the drugs may be prescribed based on the age of the patient. In this case, the patient was given many antihypertensive drugs because his blood pressure was too high. Also, the nurse may have recommended the drugs because the patient’s immune is low due to his age. The other diseases affecting the patient may have also contributed to the prescription of more than one antihypertensive drug.
Benefits of Aspirin Therapy
The first benefit of aspirin to this patient is that it reduces the risks of developing stroke and heart attack. The patient is an older person, and thus the risks suffering from dementia. According to Cahill et al. (2019), using aspirin can reduce the risk of suffering from the disease. The patient can also use the drug to relieve pain.
References
Bruchfeld, A., & Lindahl, K. (2019, March). Direct acting anti‐viral medications for hepatitis C: Clinical trials in patients with advanced chronic kidney disease. In Seminars in dialysis (Vol. 32, No. 2, pp. 135-140).
Cahill, K. N., Cui, J., Kothari, P., Murphy, K., Raby, B. A., Singer, J., … & Laidlaw, T. M. (2019). Unique Effect of Aspirin Therapy on Biomarkers in Aspirin-exacerbated Respiratory Disease. A Prospective Trial. American Journal of Respiratory and Critical Care Medicine, 200(6), 704-711.
Wang, X. L., Qi, J., Shi, Y. Q., Lu, Z. Y., Li, R. L., Huang, G. J., … & Li, Y. (2019). Atorvastatin plus therapeutic ultrasound improve postnatal neovascularization in response to hindlimb ischemia via the PI3K-Akt pathway. American Journal of Translational Research, 11(5), 2877.
