ACS Case Presentation

Done By:

Sara AlArfaj, Pharm D, KSU

Patient’s information:

AN, is a 77 yo male

Chief Compliant:

Central chest pain and SOB for 2 days

HPI

• Admitted to ward 2.8 as a case of ACS

“NSTEMI”,DHF, Pulmonary Edema and

Respiratory distress

• ECHO showed

LVSF was severly reduced

EF 30-35%

Severe AS

• Patient was started in IV diuretics

“Furosemide and Metolazone”

• S/P Chest Drain

• On 28/3 started on IV Abx “Tazocin

and Azithromycin”

• Patient desaturated and started on

BiPAP then shifted to CCU-A

PMH

• IHD S/P CABG in 2002

PCI in 2013 at KFSH&RC

• IDDM on insulin, 11 years ago

• CKD

• HTN, 4 years ago

• DLP

Family history:

Not available

Social History:

Not available

Allergies:

None

Vital Signs

Temp = 36.9

SpO2 = 98%

RR = 19

BP = 124/41

HR = 56

Wt = 56.3 kg

Physical Examination

• GEN: Patient was in pain with respiratory

distress

• CNS: GCS 15/15, patient’s alert and

responsive

• CVS: S1 + S2, no abnormalities

• Chest: Coarse crackles with tachypnea

• ABD: Non-tender with hypoactive BS

• CXR:Pleural effusion

• ECG:NSTEMI

• ECHO: Left ventricle is mildly dilated

LVSF is mod-severely reduced

EF = 30-35%

Low gradient AS “ needs Dobutamine Echo to determine AS severity”

Cath Report at KFSH

• Angiography:LM: distal diffuse 90% stenosis

LAD: totally occluded proximally

LCX: totally occluded at origin

RCA: proximal diffuse 90% stenosis then totally occluded

• Impression: 3VD, patent grafts

• Plan: For medical therapy as no value of

Revascularization

Past Medication History:

Medication Medication

Amlodipine 5 mg PO OD Furosemide 5 mg PO BID

Aspirin 81 mg PO OD Metoprolol 50 mg PO BID

Clopidogrel 75 mg PO OD Omeprazole 20 mg PO OD

Atorvastatin 20 mg PO OD Loperamide 10 mg PO BID

Isosorbide Dinitrate 40 mg BID Docusate Sodium 100 mg PO BID

Laboratory Data

CUEM

28 29 30 1 2 3 4 6 8 10 13

Na 138 137 130 136 135 136 134 140 138 137 134

K 3.3 3 3.3 2.8 2.5 3.2 4.6 4.5 4.3 4.1 3.9

Mg 1.01 1.13 1.06 0.9 0.93 0.86 0.96 1.02 0.87 0.78 0.86

Ca 2.38 2.38 2.37 2.58 2.68 2.65 2.41 2.47 2.5 2.45 2.44

U 41.3 46.7 49.1 20.4 15.2 12.3 29.6 22.1 17.3 15.4 21.0

Cr 362 397 350 142 121 119 228 175 157 164 197

Na: 135- 145K: 3.2- 5Mg: 0.74-1Ca :2.09-2.51

Urea: 2.3-7.5Cr: 59-104

CBC

Coagulation

28 29 30 1 2 3 4 6 8 10 13

WBC 8.80 8.6 4.40 5.10 6.90 6.50 7.2 6.8 6.40 5.0 4.2

RBC 4.78 4.6 4.37 5.14 5.19 5.62 4.5 4.27 4.14 4.3 4.07

HGB 11.1 11 10.1 11.8 12.2 13.3 10.7 9.9 9.6 9.9 9.6

PLT 159 159 159 182 205 239 196 212 242 253 283

28 29 30 1 2 3 4 6 8 10 13

PT 9.9 9.7 8.9 8.7 7.9 7.8 8.3 8.4 19.2 36.7 8.8

APTT 36 34 34 65 28 26 38 47 153 43 38

INR 1.2 1.1 1.1 1.1 1 1 1 1 2.1 3.7 1.4

WBC: 4.0 – 11.0

RBC: 4.20 – 6.20HGB: 12.5 – 18.0PLT: 150 – 450PT: 7.6 – 9.9

APTT: 27 – 40

INR: 0.9 – 1.1

Cardiac Enzymes

Liver

28 29 30 1 2 3 4 6 8 10 13

TnT 0.45 0.39 0.18 0.22 0.27 0.22 0.22 0.20

CK 68 51 34 50 83 78 54 45 49 44 34

LDH 231 188 175 333 256 284 207 208 192 194 197

28 29 30 1 2 3 4 6 8 10 13

ALT 42 33 26 25 42 68 40 33 29 20

AST 19 15 13 21 44 56 35 30 24 21 18

ALP 85 74 83 98 91 106 67 72 73 67

cTnT: 0.1CK: 50 – 190 U/LLDH: 135 – 255 U/L

ALT: 2 – 40 U/LAST: 2 – 37 U/LALP: 40 – 129 U/L

Medication status Medication status

Aspirin 81 mg PO OD Ivabradine 7.5 mg PO Q12 hrs DC’ed1/4(low HR)

Clopidogrel 75 mg PO OD Pregabaline Capsule 75 mg PO

OD

Atorvastatin 40 mg PO OD Trimetazidine 35 mg PO Q 12 hrs

Bisoprolol 2.5 mg PO OD Azithromycin 500 mg PO OD DC’ed 4/4(7 days completed)Calci Heparin 5000 units SC Q12 hrs Tazocin 2.25 g PO Q 12 hrs

Furosemide 40 mg IV Q 12 hrs Renal function

Hydralazine 25 mg PO BD

Esmoprazole 40 mg PO OD Isosorbide Dintirate 20 mg BD

Calcium Carbonate 600 mg PO Q24 hrs

Mixt. Insulin •16 U SC predinner•20 U SC breakfast

One Alpha 0.25 mcg PO OD

Scheduled Medications:

Medications

Dopamine 3

mcg/kg/hr

DC’ed 2/4

Heparin Infusion

(protocol)

Started 5/4

Medications

Acetaminophen 1000 mg PO

Lactulose 20 ml PO

Mg Gluconate 1000 mg PO

KCL 24 mEq PO

Regular Insulin sliding scale

Continuous Infusion:

PRN:

Problem List

ACS

DHF

IDDM

CKD

HTN

DLP

IHD HF DM CKD

S CP and SOB SOB

O ECG: NSTEMITn: 0.45HR: 56 (sinus brady)

EF= 30-35 %

ProBNP= 4321

CXR: congestion with

left pleural effusion

BSL= 5.5“no HbA1C%available”

Cr= 362U= 41.3Balance= -1263.7CrCL= 11.9 ml/min

A Stable 2ry to chest infection?

Congested

Diabetes associated

Nephropathy

P • Shifted to CCU-A

due to destauration, strated on BiPAP

• Medications:Aspirin

Clopidogrel

Bisoprolol

Atorvastatin

Heparin

Trimetazidine

• Pleural drain

• Medications:Bisoprolol

Furosemide 40 mg

IV Q12

Ivabradine

Dopamine 3

mcg/kg/min

Insulin Sliding

Scale

• Fluid restriction

• If congestion is not better consider HD

• Medications:Furosemide

Dopamine

Day 1 (28/4)

HTN DLP

O BP= 142/41 No lipids profile for this patient

A BP is controlled

P Continue same

management

Atorvastatin 40 mg OD

IHD DHF DM CKD

S c/o SOB c/o SOB

O Tn: 0.45- 0.39HR: 52

EF: 30-35%CXR: pleural effusion

BSL: 7.7 - 18 Cr= 397- 350 U= 46.7 – 49.1Balance= - 496CrCL= 11.4 ml/min

A HD stable Stable but still congested

Not controlled AKI on top of CKD

P • Aspirin• Clopidogrel• Bisoprolol• Atorvastatin• Heparin• Trimetazidine

• Bisoprolol• Furosemide 40 mg

IV Q12 • Ivabradine• Dopamine 3

mcg/kg/min

Sliding scale insulin

• Hold or reduce diuretics

• CRRT if congestion is not better

Day 2-3

IHD DHF DM CKD

O Tn= 0.45 – 0.18

HR= 68

EF= 30-35% BSL= 11.2 Cr= 142

U= 20.4

Balance= -524

CrCL= 30.3 ml/min

A No active compliant

P • Hold Ivabraidine

• Hold Bisoprolol if HR<50

Insulin sliding

scale

• DC Lasix

• Started HD for 3

consecutive

sessions

Day 4

IHD DHF DM CKD

O Tn= 0.45-0.22

HR= 77

EF= 30-35%

HR= 77

BP= 123/54

BSL= 14.4-9.4 Cr= 121-119

U=15.2- 12.3

Balance= -1973

CrCl=35 ml/min

A No active compliant Not controlled stable

P Same

management

• Hydralazine 25

mg PO BD

• Isosorbide

Dinitrate 20 mg

PO OD

Mixt. insulin

added with

sliding scale

• Finished 3

sessions of

dialysis

• Dopamine

DC’ed

Day 5-6

IHD DHF DM CKD

S Chest pain

O Tn= 0.27

HR=78

EF= 30-35%

Chest is clear

BSL= 17.9-8.8 Cr= 228- 175

U= 29.6 – 22.1

Balance= -422

CrCl= 24.2 ml/min

A Patient is stable

P Calci Heparin was

held and Started

on Heparin

infusion

Same as beofre Mixt. Insulin +

Sliding scale

No need for HD

Day 7-9

IHD DHF DM CKD

O Tn= 0.22

HR= 82

developed

paroxysmal AF

EF= 30-35%

HR= 82

BP= 106/47

CXR: congestion

BSL= 6.2-8 Cr= 157

U=17.3

Balance= -382

CrCl=26 ml/min

A Stable

P 7/4: Received

Warfarine 7 mg

PO

9/4: Heparin DC’ed

(PT= 153)

• Same

management

• For Dobutamine

Echo

Mixt. Insulin with

sliding scale

• If UOP < 1.5

L/24 hrs,

resume

diuretics

Day 10- 12

IHD DHF DM CKD

O Tn= 0.20

HR= 80

EF= 30-35%

HR= 80

BP= 126/60

BSL=8.6-11.6 Cr= 197

U=21

Balance= -382

CrCl=21.4 ml/min

A Stable

P INR = 3.7

Warfarine 3 mg

PO OD

Same

management

Mixt. Insulin

with sliding

scale

IV Lasix to Oral 40

mg BD

Day 13 - 15

Recommendations

Spironolactone and Eplerenone can cause hyperkalaemia and worsening

renal function, which were uncommon in the RCTs, but may occur more

frequently in ordinary clinical practice, especially in the elderly. Both

should only be used in patients with adequate renal function and a normal

serum potassium concentration (ESC)

Thank You..

Questions?