About Coronary artery disease with left ventricular dystrophy treatment, care plan, monitoring, counselling and precautions

1. CORONARY ARTERY DISEASE WITH
LEFT VENTRICULAR DYSFUNCTION
AND GENERAL EDEMA
By
Goutham Kondeti

2. Patient Profile Form:
Name: Venkata Lakshmi
Age:45
Gender: Female
DOA:9/3/2013
Unit: Cardiology Department - 1

3. Complaints:
Decreased Urine Output, Vomiting’s since 3 days,
Body pains, Chest pain, general lymphadenopathy
Past Medical History: Chest pain and under went
Percutaneous Trans luminal Angioplasty
Habits: Mixed diet
General Examination: moderately built and
moderately nourished, pallor, paedal edema, facial
puffiness

4. Pharmaceutical Care Plan:
Subjective Evidence: decreased urine output, Vomiting’s
Since 3 days, body pains, chest pain, underwent PCTA.
Objective Evidence: Angiography-shows the cholesterol
blocking coronary artery
Veins in neck are too big and swelling at feet and
abnormal ECG

5. Lab Investigations
Blood sugar-94mg/dl
Blood Urea-53mg/dl
Serum Creatinine-1.0mg/dl

6. Assessment
Based on subjective and objective
evidence is Coronary Artery Disease
with Left Ventricular Dysfunction and
General Edema

7. Goals of Treatment
 Primary goal is to reduce the chest pain.
 To increase the urine output.
 To reduce edema
 To reduce vomiting’s.
 To decrease arrhythmias
 To improve the quality of life of patient

8. Treatment Options
Anti-Thrombotic drugs- Aspirin
Clopidogrel
Lipid Lowering Agents-Statins-Atorvastatin
Simvastatin
Lovastatin
Cholesterol Absorption Inhibitors-Ezetimibe
Fibrates-Clofibrate
Fenofibrate
Nitrates-Isosorbide Dinitrate
Isosorbide mononitrate
Diuretics-Furosemide

9. Antibacterial Agents-Ceftriaxone
Metronidazole
Ciprofloxacin
Anti-Ulcerative Drugs-Pantoprazole

10. Assessment
 Nitrates are preferred to dilate veins and decreasing
preload and dilating arteries to less extent and decreasing
after load.
 Antithrombotic drugs are preferred because of having
anti-platelet action.
 Lipid Lowering agents are preferred to reduce the levels
of triglycerides, LDL-C,VLDL-C and total cholesterol.
 Diuretics are preferred to increase the urine output and
reduce the edema.

11. Anti-bacterial agents are preferred because cardiac
catherisation and decreased urine output can cause
infections.
Anti-Ulcerative drug is preferred to avoid ulcers form due to
Antithrombotic drugs and Ciprofloxacin.

12. Day-1:
Patient is concious and coherent
B.P-100/60mmHg
PR-82/min
CVS-S1 S2 +
Lungs-Clear
P/A-Soft

13. Day-2:
Patient is conscious and coherent
Tachypnoea
B.P: 70/50mmHg
CVS-S1S2 heard Tachycardia
P/A: soft
RS:B/L crepts

14. Day-3:
B.P:110/70 mmHg PR-70/min
Tachypnoea CVS:S1S2 Tachycardia
RS:B/L Crepts P/A: Soft
Pedal edema
Facial puffiness

15. Day-4:
B.P-110/70mmHg
PR-72/min
CVS-S1S2+
P/A-Soft RS-B/L crepts
Pedal edema
Facial Puffiness

16. Day-5:
B.P: 90/60mmHg
PR-76/min
CVS-S1S2+
P/A-Soft
RS-B/L Crepts
Pedal edema

17. Day-6
Patient is conscious and coherent
B.P-110/70mmHg
P.R-70/min
CVS-S1S2+
P/A-Soft
Pedal edema

18. Day-7:
B.P-120/80mmHg
P.R-80/min
CVS-S1S2+
RS-B/L NVBS

19. Dose Frequency ROA Day-1 Day-2 Day-3 Day-4 Dsy-5 D
loxacin 1 bottle BD IV     _ _
nidazole 1 bottle TID IV      
mide 1 ampule BD IV      
in 150mg OD orally      
astatin 10mg OD orally      
dogrel 75mg OD orally      
trate 10mg TID orally      
hydrinate o.4cc BD SC    _ _ _
xone 1gm BD IV      
razole 40mg OD IV      

20. Goals Achieved
Chest pain was reduced on 6th day.
Normal cardiac rhythm was achieved by 4th day.
Vomiting’s were subsided by 3rd day.
Urine Output was increased on 5th day.
Facial puffiness was reduced on 5th day.
Pedal edema was reduced on 7th day.
By controlling these cardiac arrest was prevented.

21. Monitoring Parameters
 Monitor Blood Pressure regularly.
 Monitor Heart rate regularly.
 Monitor lipid levels regularly.
 Monitor For Sudden Cardiac arrest or Stroke.
 Monitor Ciprofloxacin can cause chest pain and cardiac
arrest.
 Monitor for any adverse drug reactions.

22.  Monitor for GI bleeding caused by Aspirin and
Clopidogrel.
 Monitor for higher risk of bleeding,bruising on
skin,bleeding from gums,bloody mucus after coughing or
vomting,blood in urine,Nose bleeds

23. Problems Identified
 Furosemide with pantoprazole lowers magnesium levels
and causes serious adverse events such as muscle spasm
,Epilepsy and Arrhythmia's.
 Ceftriaxone with loop diuretics increase the risk of
Nephrotoxicity.
 Concomitant use of statins and pantoprazole
competitively inhibits P-gp transport system,t his may
lead to increased intestinal absorption/decreased hepatic
excretion of either product resulting increased drug
bioavalability leads to serious adverse events like serious
myopathies

24. Patient Counseling
About Disease:-
Coronary Artery Disease-Coronary artery disease is a medical
condition caused by the abnormal buildup of fatty plaques
(atherosclerosis) within the arteries that bring blood to your heart.
It may lead to other complications like Heart Failure, Sudden
Cardiac Arrest,Stroke,Aneurysm and Peripheral Arterial Disease.

25. Left Ventricular Dysfunction
Left ventricular dysfunction means that the main pumping
chamber of your heart (left ventricle) is not working well. The
heart is a muscle and needs a constant supply of oxygen and
blood. If the arteries that deliver the oxygen and blood are
blocked, parts of the heart may get weak and not pump well. The
heart may also get weak from having to constantly pump against
the resistance of high blood pressure or narrow arteries

26. Symptoms may progress to include:
 Fatigue.
 Reduced ability to exercise.
 Trouble breathing, especially when active.
 Shortness of breath at rest.
 Trouble breathing when lying down at night.
 Being more tired, lightheaded, or confused.
 Weight gain with swelling of the legs and feet.

27. General Edema
Edema is a condition of abnormally large fluid volume in the
circulatory system or in tissues between the body's cells (interstitial
spaces).
Description
Normally the body maintains a balance of fluid in tissues by ensuring
that the same of amount of water entering the body also leaves it. The
circulatory system transports fluid within the body via its network of
blood vessels. The fluid, which contains oxygen and nutrients needed
by the cells, moves from the walls of the blood vessels into the
body's tissues. After its nutrients are used up, fluid moves back into
the blood vessels and returns to the heart.

28. The lymphatic system (a network of channels in the body that carry
lymph, a colourless fluid containing white blood cells to fight
infection) also absorbs and transports this fluid. In edema, either too
much fluid moves from the blood vessels into the tissues, or not
enough fluid moves from the tissues back into the blood vessels.
This fluid imbalance can cause mild to severe swelling in one or
more parts of the body.
Heart failure. When the heart is unable to maintain adequate blood
flow throughout the circulatory system, the excess fluid pressure
within the blood vessels can cause shifts into the interstitial spaces.
Left-sided heart failure can cause pulmonary edema, as fluid shifts
into the lungs. The patient may develop rapid, shallow
respirations, shortness of breath, and a cough. Right-sided heart
failure can cause pitting edema, a swelling in the tissue under the
skin of the lower legs and feet.

29. About Drugs
Inj.Ciprofloxacin-It is an Anti-bacterial drug given
intravenously twice in a day.
Dose-1 bottle
Side effects-Nausea, vomiting, heartburn, stomach pain
Inj.Metronidazole-It is an Anti-bacterial drug given
intravenously thrice in a day.It should be taken 1hr before
meals or 2hrs after meals.
Dose-1 bottle
Adults : Initially, a loading dose of 15 mg/kg IV over 1
hour followed by 7.5 mg/kg IV every 6 hours.
Side effects-GIT disturbances, mild Leukopenia
serious side effect is pancreatitis

30. Inj.Furosemide-It is an diuretic given intravenously twice a
day
Dose-1 ampule
Side effects-hyperkalemia, metabolic acidosis,uraemia
Tab.Aspirin-It is an Anti-platelet drug given orally
Dose-150mg
Side effects-GI bleeding
Tab.Atorvastatin-It is a lipid lowering drug given orally.
Dose-10mg
Side effects-Myalgia, GI disturbances, Angio edema

31. Tab.Clopidigrel-It is an Anti-Platelet drug given orally once a
day.
Dose-75mg
Side effects-GI bleeding
Tab.Sorbitrate-It is a vasodilator given orally thrice in a day.
Dose-10mg
Side effects-Postural Hypotension,Tachycardia,headache
Inj.Dimenhydrinate-It is an Anti-emetic given
subcutaneously two times a day.
Dose-0.4cc
Side effects-: headache, blurred vision, xerophthalmia,
tinnitus, nasal dryness, dry throat, incoordination (ataxia),
confusion, impaired cognition, and dizziness.

32. Inj.Ceftriaxone-It is an Anti- bacterial drug given
intravenously twice a day
Dose-1gm
Side effects-Nephrotoxicity, hypersensitivity
Inj.Pantoprazole-It is an Anti-ulcerative drug given
intravenously once a day.
Dose-40mg
Side effects-Headache, diarrhoea,low magnesium blood level,
muscle spasms, seizures, Irregular heartbeat,
Stomach pain/cramping, fever, blood/mucus in
your stool.

33. About Life Style Modifications:
Activity Level--- It is important to maintain strength and
increase it if possible. Pace activities and avoid shortness
of breath or chest pain. Plan activities for at least an hour
after meals or before eating. This allows the body to
handle one activity at a time.
Diet---Follow a heart-healthy diet. Diet is very important
to heart health.
 Eat plenty of fresh fruits and vegetables. Meat should
be lean cut.

34. Weight Monitoring---When get home, compare it to scale and
record the weight. Weigh twice per day at first and record these
weights. Try to weigh at the same time every day.
Blood pressure monitoring should be done twice a day at first,
morning and evening when relaxed. Once blood pressure has
stabilized, rechecking once a day and then a few times a week may
be enough. Get a home blood pressure cuff at drugstore. Record
these values and bring them to clinic visits.

35. Avoid the following types of food:
 Food that is high in salt.
 Canned or highly processed food.
 Food that is high in saturated fat or sugar.
 Fried food
Being familiar with medications--- If having trouble remember
when took them, write down times or set medications out in
advance for the day or the week to avoid problems. If taking
medications twice a day, place them by the side of toothbrush and
get in the habit of brushing teeth twice a day.
 Don’t skip medicines or add medicines.

36. SEEK IMMEDIATE MEDICAL CARE IF:
 If weight increases by 3 lb/1.4 kg in 1 day or 5 lb/2.3 kg in a
week, or as physician suggests
 If notice increasing shortness of breath during rest, sleeping,
or with activity, and which is unusual for the person.
 If develop an increase in angina, or develop chest pain which
is unusual for the person.
 If develop sweating or nausea which is unusual for the person.
 If notice swelling in hands, feet, ankles or abdomen.
 If have a feeling of fullness in abdomen or develop nausea or
loss of appetite.
 If noticed lasting (persistent) dizziness, blurred vision,
headache, or unsteadiness.