Hypertensive Coronary Artery Disease

post Coronary Artery Bypass Grafting

Gladys S. Marcos, RPh

Doctor of Pharmacy
CASE PROPER
Critical Care
 Patient’s Demographic Data
• NAME: ZMP
• AGE: 76 y/o
• SEX: Male
• WEIGHT: 58.10 kg
• ALLERGY: Allopurinol, Augmentin, Levox
• DATE ADMITTED: 31 December 2010
• CHIEF COMPLAINT
– Fever and difficulty of breathing

• HISTORY OF PRESENT ILLNESS

– 5 days PTA, patient started to have productive cough
with yellowish sputum, this was accompanied by
chills. There was no fever, no dyspnea, no colds, no
sore throat, no dysuria, no nausea, no vomiting, no
diarrhea.
– 3 days PTA, patient was noted to be more drowsy and
there was increase in severity of cough. Oxygen
saturation taken at home was 92% (lower than his
usual O2 sat of 96%)
• HISTORY OF PRESENT ILLNESS
– 1 day PTA, patient was seen by his physician and
was told have atelectasis, he was advised to
continue antibiotics and was prescribed with
Difluconazole 200mg/tab 1 tab once a day due to
presence of oral thrush. Later that day, patient
started to develop fever (Tmax 38C) which was
lysed by Paracetamol.
– 3 hours PTA, still with febrile episodes started to
have difficulty of breathing. O2 sat at room air
was as low as 61% and 89% oxygen. Due to
persistence of dyspnea, hence this admission.
REVIEW OF SYSTEMS
(-) weight gain (-) jaundice
(-) rash (-) constipation
(-) headache (-) diarrhea
(-) dizziness (-) urgency
(-) colds (-) frequency
(-) palpitations (-) nocturia
(-)syncope (-) hematuria
(-)dyspnea on exertion (-) polyuria
(-) edema (-) oliguria
(-) loss of appetite (-) limitation of motion
(-) heartburn (-) bleeding tendency
(-) abdominal pain (-) intolerance to heat or cold
PAST MEDICAL HISTORY
(+) Hypertensive Coronary Artery Disease more than 20
years
(+) post Coronary Artery Bypass Grafting, 3 vessel disease
in 2005, Asian Hospital
(+) Diabetes Mellitus x 20 years, recent prebreakfast
CBGs 57-107
(+) Chronic Kidney Disease – usual creatinine less than
2mg/dl
(+) Tuberculosis – treated on unrecalled year
(-) Asthma, Cancer
(+) Allergy: allopurinol, Co-amoxyclav, Levofloxacin -
rashes
CURRENT MEDICATIONS
• Humalog 10-26-15
• Sitagliptin 50mg/tab 1tab
OD
• Clopidogrel 75mg/tab
1tab OD
• Amlodipine 5mg/tab
½tab OD
• Colchicine 5mg/tab 1tab
2x/day
• Sodium bicarbonate
650mg/tab 2tabs 3x/day
• Folic acid 1tab OD
• Olanzapine ½tab 2x/day
• Vitamin B 500mg/tab
1tab OD
• Acetylcysteine 600mg/tab
1tab OD
• Pregabalin 75mg/tab
1tab 2x/day
• Ipratropium+Salbutamol
1neb 3x/day
• Furosemide 40mg/tab
½tab Mon-Wed-Fri
• Spirinolactone 25mg/tab
1tab Mon-Wed-Fri
• Epoietin 5000units every
Mon-Wed-Fri
FAMILY HISTORY SOCIAL
HISTORY
(-) Hypertension (-) smoker
(-) Diabetes (-) alcoholic beverage
(-) Asthma drinker
(-) Cancer (-) illicit drug use
PHYSICAL EXAMINATION
• Conscious, coherent, • No carotid bruits, no lifts
speaks in phrases, in or heaves
cardiorespiratory distress • Equal chest expansion, no
• Temp = 38C; BP = retractions, (+) bilateral
130/70mmHg; HR = 118 crackles more on the
beats/min; RR = 28 right, (+) bilateral
cycles/min wheezes
• Anicteric sclera, pink • Full and equal pulses
conjunctiva, (+) minimal • No cyanosis, clubbing of
curdlike material, no extremities
tonsillar exudates • No lymphadenopathy
IMPRESSIONS
• Health Care Associated Pneumonia
• Hypertensive Coronary Artery Disease post
Coronary Artery Bypass Grafting, 3 vessel
disease in 2005
• Diabetes Mellitus
• Chronic Kidney Disease
• Tuberculosis, Category 5
• Oral Thrush
DIAGNOSTICS
• Chest X-ray
• 12L ECG
• CBC
• Serum Na, K
• Creatinine, BUN
• Sputum GS/CS
• ABG
• CBG
CT SCAN OF THE CHEST W/O
CONTRAST (12/31/2010)

IMPRESSION

• Interval progression of pulmonary

consolidation in both lungs as described.
Pneumonia is primarily considered.
ECG REPORT (01/08/2011)
FINDINGS: Concentric LVH. Calculated LVEF 55%
by Teicholz 56% by Simpsons. Normal left &
right atria, right ventricle. Normal main
pulmonary artery & aortic dimensions.
Calcified aortic walls.
CFD Study: Abnormal LV diastolic function
indices.
 Laboratory and Results (CBC)
Reference 12/31 01/01 01/02 01/04 01/07 01/10 01/12 01/15 01/17 01/19 01/21
range

Hemoglobin 14-17.5 g/dL 12.70 12.90 10.30 12.70 13.30 12.10 12.70 12.30 12.90 14.10 14.70

Hematocrit 41.5-50.4 % 44.00 44.60 42.20 44.50 49.40 41.80 42.70 40.60 42.10 47.00 50.20

RBC 4.5 -5.9 5.81 9.70 5.86 5.72 6.00 6.55 6.94
x10^6/uL
WBC 4.4-11 8.99 16.53 8.64 9.33 14.49 10.81 9.11 15.87 18.19
X10^3/uL
Segmenters 40-70% 81.00 85.00 91.00 90.00 90.00 85.00 86.00 79.00 79.00 85.00 81.00

Lymphocytes 22-43% 9.00 5.00 2.00 4.00 4.00 10.00 7.00 10.00 11.00 7.00 9.00

Eosinophils 0-4 1 1 2 2 1 2

Monocytes 0-7 % 8 5 3 5 5 5 6 9 8 6 8

Platelet count 150,000 – 198, 192, 233, 238, 200, 247, 244, 282, 302, 308, 331,
450,000u/L 000 000 000 000 000 000 000 000 000 000 000

MCV 80 – 96 um^3 75.70

MCH 27.5-33.2 pg 21.90

MCHC 33.4-35.5 % 28.90

RDW 11.60–14.60 17.20

%
 Laboratory and Results
Reference 12/31 01/01 01/02 01/04 01/07 01/10 01/12 01/15 01/17 01/19 01/21
range

Sodium 136-145 142 142 140 153 152 143 143 131 130 135 141
meq/L 154 147 145 139
Potassium 3.1-5.1 meq/L 5.4 4.5 4.2 3.8 4.7 4.2 4.3 4.0 3.8 4.4 5.4
4.1 4.9 3.9 4.3
BUN 8-23 mg/dL 30.34 45.95 70.26 57.17 58.57 68.07 43.35 44.24 47.08 48.04 57.76
51.14 61.35 68.97 49.15
65.06

Creatinine 0.70-1.20 1.96 2.32 2.77 2.20 2.31 2.87 1.81 1.96 2.11 2.09 2.11
mg/dL 2.15 2.52 2.74 2.07
2.20
Uric Acid 3.4-7.0 mg/dL 10.41
Blood Sugar 431.72 mg/dL 431
Cholesterol <200 mg/dL 139.10
Albumin 3.5-5.2 g/dL 3.00
Calcium 8.6-10.2 9.44 1.29 9.42 9.3
mg/dL
Alkaline 40-130 U/L 92.00
phosphatase
Total Bilirubin 0-1 mg/dL 0.19
Carbon 22-29 meq/L 29 30 30
Dioxide
Daily Medications
• Ipratropium Bromide (Atrovent UDV) 500mcg/2mL, 1UDV+ambroxol Q6
(01jjan-28jan)
• Ambroxol (Mucosolvan) Inhalation Solution 15mL, 2mL+atrovent Q6
(01jan-28jan)
• Esomeprazole (Nexium) 40mg, 1vial OD 0600H (31dec-28jan)
• Cefepime (Sanpime) Vial 1gm, 1vial Q24H 1600H (07jan-28janLD)
• Metronidazole (Flagyl Forte) tab, 1tab Q8 (03jan-28jan)
• Almitrine+Raubasine (Duxaril), 1tab 2x/day (07jan-28jan)
• Tamsulosin HCl (Harnal) cap 200mcg, 1cap bedtime (10jan-28jan)
• Doxofylline (Ansimar) syrup 100mg/5ml, 10mL Q8 (15jan-28jan)
• Acetylcysteine (Fluimucil Effervescent) tab, 1tab+water 2x/day (20jan-
28jan)
• Sitagliptin (Januvia) tab 50mg, 1tab pre1600feeding (21jan-28jan)
• Citicholine (Zynapse) amp 500mg/4ml, 1 amp every 0800, (24jan-28jan)
• Conjugated estrogen (Premarin) tab 625mcg, 1tab 2x/day (25jan-28jan)
• Desmopressin (Minirin) tab 100mcg, 1tab OD (25jan-28jan)
 ER

COURSE Dec.31
(Admitted)

IN THE Jan.01
(Transferred-in to ICU)

WARD Jan.07
(Intubation)

Jan.12
(Self-extubation)
Jan.21
Jan.13
(Transferred-out of ICU)
(Reintubation)

Jan.29 Dec.19
(Discharged!!!) (Self-extubation)
*w/ take home meds
BACKGROUND OF THE
DISEASE
Hypertensive Coronary Artery
Disease
DEFINITION
• Hypertensive coronary artery disease is the
narrowing of the coronary artery lumen and
impairment of the antegrade myocardial
blood flow due to uncontrolled and prolonged
elevation of blood pressure (BP)
CAUSES
• The cause of hypertensive heart disease is
chronically elevated BP. The causes of elevated
BP are diverse. In adults, the following causes
should be considered:
– Essential hypertension accounts for 90% of cases of
hypertension in adults.
– Secondary causes of hypertension account for the
remaining 10% of cases of chronically elevated BP.
These include the following:
• Renal causes
• Endocrine causes
• Others (Coarctation of aorta, Raised intracranial pressure,
Sleep apnea
RENAL CAUSES
• Renal artery stenosis
• Polycystic kidney disease
• Chronic renal failure
• • Congenital adrenal hyperplasia
Intrarenal Vasculitis
ENDOCRINE CAUSES
• Primary hyperaldosteronism
• Pheochromocytoma
• Cushing syndrome
• Hypothyroidism and
hyperthyroidism
• Acromegaly
• Exogenous hormone (eg,
corticosteroids, estrogens),
sympathomimetics (including
cocaine), monoamine oxidase
inhibitors (MAOIs), and
tyramine-containing foods
SYMPTOMS
• Fatigue
• Cardiomegaly
• Irregular pulse
• Swelling of feet
• Weight gain
• Nausea
• Shortness of breath
• Difficulty sleeping flat in bed
• Bloating
• Greater need to urinate at night
DIAGNOSIS
• History
• Physical Examination
• Diagnostics and Imaging Studies
– Electrocardiography
– Chest Radiography
– Cardiac Computed Tomography Angiography
– Echocardiography
• Laboratory blood tests
– total cholesterol, high-density lipoprotein [HDL] cholesterol,
triglycerides, and calculated low-density lipoprotein [LDL] levels
• Stress testing
• Cardiac catheterization may be necessary to obtain further
diagnostic insight.
 LIFESTYLE
TREATMENT MODIFICATION
• Once a cardiac • Avoid smoking.
catheterization has • Exercise
been performed, the – at least 30 minutes of
three most common exercise 3 or 4 days a
therapeutic options are week
– medical therapy • Weight Control
– percutaneous coronary
intervention (PCI)
– coronary artery bypass
grafting (CABG).
Medications
• Antihypertensives
– thiazide diuretics,
– beta-blockers
– combined alpha- and beta-blockers
– calcium channel blockers
– ACE inhibitors
– angiotensin receptor blockers
– direct vasodilators such as hydralazine
• Intravenous drugs used in patients with a hypertensive emergency include
– Nitroprusside
– Labetalol
– Hydralazine
– Enalapril
– beta-blockers (avoided in patients with acutely decompensated heart failure).
Medications
• Antihypertensives
– thiazide diuretics,
– beta-blockers
– combined alpha- and beta-
blockers
– calcium channel blockers
– ACE inhibitors
– angiotensin receptor
blockers
– direct vasodilators such as
hydralazine
• Intravenous drugs used in
patients with a
hypertensive emergency
include
– Nitroprusside
– Labetalol
– Hydralazine
– Enalapril
– beta-blockers (avoided in
patients with acutely
decompensated heart
failure).
THANK YOU!!!!!!