A 45-year old male patient was admitted to the male medicine ward with symptoms of cough with expectoration, dyspnoea since 2 months and oedema of feet since 15-20 days.

1. A CASE STUDY ON
DCM WITH SEVERE
PAH
• AJITA SADHUKHAN
• PHARM D 5TH YEAR
• ROLL No. – 1
• ENROLLMENT No. - 150821207001

2. SUBJECTIVE EVIDENCE:
Patient OPD No. 19126109
Patient IPD No. 19016981
Department Male Medicine Ward
Unit II
Age 45 years
Gender Male
Date of Admission 28.06.19
Date of Discharge 03.07.19
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3. Reason for admission :
C/O:
- cough with expectorant
- dyspnoea × 2 months
- oedema of feet × 15-20 days
Past Medical History: NAD
Past Medication History: NAD
Family History: NAD
Social History: Ex- smoker
Previous Allergies: NKA
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Bowel + Bladder habits: Regular
Sleep: Adequate
S/O:
- Cardiomegaly with pericardial
haziness
Physical Examination:
- T/P/R: normal/118 bpm/normal
- B.P.: 110/70 mm Hg
- RS: BLAE crepts +

4. Complete Blood Count (28.06.19)
LABORATORY
PARAMETERS
OBSERVED VALUE NORMAL RANGE UNIT
Hb 13.5 12.5-16 g/dL
WBC 6580 4000-10500 /mcgL
Neutrophils 70 50-70 %
Eosinophils 3 0-7 %
Lymphocytes 24 20-40 %
Monocytes 03 <10 %
Basophils 0 <1 %
RBC 6.23 4.20-5.40 Millions/mcgL
MCH 21.7 27-31 pg
Platelets 2.52 1.5-4.5*10^5 /mcgL
MCV 67 78-100 fL
Hematocrit (PCV) 41.7 37-47 %
MCHC 32.4 32-36 g/dL
RDW-CV 15 11-14.6 %
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5. • 28.06.19
1. ECG:
- Extreme tachycardia
- Poor R wave progression
- Inverted T wave
- Excessive overload of atria
• 29.06.19
1. Renal function test:
a. S. Creatinine: 1.1 mg/dL (0.5-1.5
mg/dL)
2. Serum Electrolytes:
a. Se. Na+: 128 mmol/L (135-145)
b. Se. K+: 4.2 mmol/L (3.5-5)
c. Se. Cl-: 95 mmol/L (98-107)
3. 2D Echo: Carotid Doppler Test:
- Dilated LV with global hypokinesia
with poor systolic function
- Dilated cardiomyopathy with poor
systolic function with severe PAH
• 30.06.19
1. Lipid Profile:
a. Se. Cholesterol: 114 mg/dL (<200)
b. Se. Triglyceride: 71 mg/dL (<150)
c. Se. HDL Cholesterol Direct: 41
mg/dL (<40)
d. Se. LDL Direct: 58.8 mg/dL (<100)
e. Se. VLDL: 14.2 mg/dL (7.0-35)
f. Cholesterol : HDL: 2.7805 (0-4.9)
g. Se. LDL : HDL : Cholesterol: 1.4341
(upto 3.5)
2. TSH (3rd gen.): 1.221 uIU/mL (0.3-
5.6)
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6. ASSESSMENT
• Provisional Diagnosis: Dilated
cardiomyopathy with severe PAH
• Justification:
• A 45 year old male patient was
admitted to male medicine ward unit 2
with complaints of cough with
expectorant, dyspnoea since 2 months
and oedema of feet since 15-20 days.
• Based on subjective evidence, ECG
and 2D Echo, the patient was
diagnosed with dilated
cardiomyopathy with severe PAH .26-03-2020 6
Final Diagnosis:
Dilated
cardiomyopathy
with severe PAH

7. GOALS OF TREATMENT
• Dilated cardiomyopathy: The primary goal is to
improve cardiac function and reduce the symptoms,
lifestyle modifications that decrease symptoms and
hospitalizations and improve the quality of life.
• Pulmonary arterial hypertension: The goals of the
treatment are to alleviate the symptoms, improve the
quality of life, slow the progression of the disease and
improve survival. A general goal of PAH treatment is to
correct the balance between vasoconstriction and
vasodilation and prevent adverse thrombotic events to
improve oxygenation and quality of life.
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8. 2. PAH:TREATMENT
OPTIONS
1. DCM:
• Treatment of dilated
cardiomyopathy is
essentially the same as
treatment of chronic
heart failure (CHF) i.e.,
blood pressure control.
ACE Inhibitors, ARBs,
Beta Blockers,
Aldosterone
Antagonists, Cardiac
Glycosides, Diuretics
and Antiarrhythmics.

9. Day 2: 29.06.19
• Temp.: normal
• Pulse: 74 bpm
• BP: 120/80 mm
Hg
• SPO2: 98%
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Day 1: 28.06.19
• GC: stable
• Temp.: normal
• Pulse: 110 bpm
• BP: 130/80 mm
Hg
• SPO2: 98%
Day 3: 30.06.19
• GC: stable
• Temp.: normal
• Pulse: 86 bpm
• BP: 130/78 mm Hg
• SPO2: 98%
• Adv.: SRD, cardio. Ref. today, Se. lipid profile
pending, 2D Echo
Day 6: 03.07.19
• GC: stable
• Temp.: normal
• Pulse: 96 bpm
• BP: 100/60 mm Hg
• SPO2: 96%
• Adv.: CST, SRD, plan discharge
Day 5: 02.07.19
• GC: stable
• Temp.: normal
• Pulse: 93 bpm
• BP: 100/60 mm Hg
• SPO2: 96%
• Adv.: SRD
Day 4: 01.07.19
• GC: stable
• Temp.: normal
• Pulse: 80bpm
• BP: 118/76 mm Hg
• SPO2: 99%
• Adv.: Cardio. ref., collect report of lipid profile and
TSH, SRD
• Cardio. Ref.: C/O DCM/ Severe LVD, severe PAH
• P/W: CCF→ now stabilized, plan medical
management
• Adv.: Tab. Ramipril 1.25 mg HS
• Rest as per Rx chart
• Follow up in OPD after 15 days

10. Day-wise Medication Chart
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DRUG DOSE ROUTE FREQU
ENCY
INDICATIONS D
A
Y
1
D
A
Y
2
D
A
Y
3
D
A
Y
4
D
A
Y
5
D
A
Y
6
Inj.
Furosemide
10 mg (½ amp.) I.V. B.D. Pedal oedema
√
Tab. Aspirin
+Atorvastatin
(75+10) mg P.O. 0-0-1 Prevention of heart
attack and stroke
√ √ √ √ √ √
Tab.
Pantoprazole
40 mg P.O. 1-0-1 Prevention of
gastric disturbances
√ √ √ √ √ √
Tab.
Carvedilol
3.125 mg P.O. ½-0-½ PAH and DCM
√ √ √ √ √
Tab.
Spironolactone
+ Torsemide
(50+10) mg P.O. 1-1-0 Pedal oedema
√ √ √ √ √
Tab. Ramipril 2.5 mg P.O. 0-0-½ PAH and DCM
√ √ √

11. Discharge Medication Chart
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Adv.: (i) Take the above medications for 7 days
(ii) Follow-up in OPD on Thursday
DRUG DOSE ROUTE FREQUENCY INDICATIONS
Tab. Methylcobalamin, alpha
lipoic acid,benfotiamine, biotin,
inositol, taurine, pyridoxine, Vit. E
- P.O. 1-0-1 Nutritional vitamin
and mineral
supplement for
healthy functioning
of nerves and body
Tab. Aspirin +Atorvastatin (75+10)
mg
P.O. 0-0-1 Prevention of heart
attack and stroke
Tab. Pantoprazole 40 mg P.O. 1-0-1 Prevention of
gastric disturbances
Tab. Carvedilol 3.125 mg P.O. ½-0-½ PAH and DCM
Tab. Spironolactone + Torsemide (50+10)
mg
P.O. 1-1-0 Pedal oedema
Tab. Ramipril 2.5 mg P.O. 0-0-½ PAH and DCM

12. GOALS ACHIEVED
• No fresh complaints.
• General condition of patient was stabilized.
• Blood pressure was controlled.
• Patient felt better.
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13. MONITORING PARAMETERS
❑ Disease related :
1. DCM: ECG, Exercise tests (treadmill test), Holter monitoring, echocardiogram,
MRI, Electrophysiology study, Coronary angiography, myocardial perfusion scan,
transoesophageal echocardiogram.
2. PAH: ECG, pulmonary wedge pressure
❑ Drugs related :
1. Furosemide → B.P., Se. Electrolytes, Se. Creatinine and BUN, BT and CT, LFT,
RFT.
2. Aspirin + Atorvastatin → ECG, ESR, CRP + Lipid profile, LFT
3. Pantoprazole → Endoscopy, Urea Breath test, Se. Mg 2+, Se. Vit. B12
4. Carvedilol → B.P., ECG, symptomatic
5. Spironolactone + Torsemide → B.P., UOP, RFT, Se. Electrolytes, uric acid, blood
glucose
6. Ramipril → B.P., ECG, Se. K+, RFT, WBC
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14. POINTS TO BE INTERVENED WITH
THE DOCTOR
Drug-Drug Interactions:
– Aspirin + Ramipril → Moderate: may result in decreased
effectiveness of ramipril.
– Aspirin + Carvedilol → Moderate: May result in
increased blood pressure.
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15. PATIENT COUNSELLING:
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ABOUT DISEASE:
1. Dilated cardiomyopathy (DCM) is a
condition in which the heart's ability to
pump blood is decreased because the
heart's main pumping chamber, the left
ventricle, is enlarged and weakened. In
some cases, it prevents the heart from
relaxing and filling with blood as it
should.
2. Pulmonary arterial hypertension
(PAH)is a type of high blood pressure
that affects arteries in the lungs and in
the heart. It is characterized by a
progressive and sustained increase in the
pulmonary vascular resistance that
eventually may lead to right ventricular
failure. It can be a life-threatening
condition if untreated.

16. 26-03-2020 16
ABOUT DRUGS:
•Aspirin + Atorvastatin: Take one tablet daily at night after dinner at the same time with a glass full
of water. Stop taking the drug in case of any unusual or excessive bleeding, GI ulceration,
rhabdomyolysis or myopathy. Side effects may include dyspepsia, agitation, confusion, dizziness,
headache, lethargy, Reye’s syndrome, seizures, diarrhoea, UTIs, extreme pain, nasopharyngitis and
arthralgias. Avoid excessive quantities of alcohol or grapefruit juice.
• Pantoprazole: Take one tablet each at least 30 mins before meal once at morning and the other at
night. Stop the drug in case of cutaneous or SLE. Side effects may include osteoporosis related
fractures (on long term use), abdominal pain, nausea, vomiting, diarrhoea, flatulence, dizziness,
headache, fever, rash and arthralgia.
• Carvedilol: Take ½ tablets once in morning and another at night with food. Don’t discontinue the
drug suddenly. Immediately report to your physician in case of hypotension, arrythmias, syncope,
palpitations, angina or edema. Side effects may include diarrhoea, nausea, vomiting, arthralgia,
dizziness, back pain, myalgia, headache, vision disorder, erectile dysfunction, reduced libido or fatigue.
• Spironolactone + Torsemide: Take the tablet consistently before or after meal once in the morning
and another at afternoon. Consult the physician in case of gynaecomastia, dehydration, hypotension,
ototoxicity, light-headedness, syncope or symptoms of worsening renal function. Side effects include
diarrhoea, nausea, vomiting, abdominal cramping, fever, leg cramps, lethargy, mental confusion,
decreased libido, excessive urination and rash. Avoid the use of non-prescription NSAIDs.
• Ramipril: Take ½ tablet everyday at night with or without food. Avoid activities requiring mental
alertness or coordination. Stop taking the drug in case of angioedema, unusual bleeding or infections,
Side effects may include dizziness, nausea, vomiting, persistent cough and fatigue. Arise slowly from a
sitting or lying position. Maintain adequate hydration. Avoid potassium supplements.
•Dibnerve: Take 2 tablets a day after meal once in morning and another at night.

17. LIFESTYLE MODIFICATIONS:
i. DCM:
a) Salt restriction, no excessive activities, bedrest.
b) Eat Healthy. Eating a variety of fruits,
vegetables, and whole grains and choosing lean
meats and fish can help improve the patient’s
heart health.
ii. PAH:
a) Immunizations against influenza and
pneumococcal diseases should be provided.
b) Hypoxemia may aggravate vasoconstriction in
such patients, therefore they may require
supplemental oxygen, particularly when using
air travel.
c) Patients should adhere to a low-sodium diet to
avoid fluid retention predisposing to right heart
failure.
d) Cardiopulmonary rehabilitation improves
functional status and is safe and important for
patients with PAH.
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20. REFERENCES :
• A textbook of Pharmacotherapy : By Joseph P.
Dipiro and Robert L. Talbert, 7th Edition, Mc-
Graw Hill Publications
• Medscape
• Cims
• Micromedex
• Mayoclinic.com

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