PHR 5515 Clinical Pharmacy PDF

PHR 5515 Clinical Pharmacy Dr Francesca Wirth Learning objectives To demonstrate a comprehensive understanding of evidence-based pharmacotherapy for cardiovascular disease in view of other comorbidities To analyse patient information and recommend appropriate clinic...

PHR 5515 Clinical Pharmacy Dr Francesca Wirth Learning objectives To demonstrate a comprehensive understanding of evidence-based pharmacotherapy for cardiovascular disease in view of other comorbidities To analyse patient information and recommend appropriate clinical pharmacy management plans for patients with cardiovascular disease in view of other comorbidities Overview ▪ Hypertension ▪ Coronary artery disease: Stable angina, Acute Coronary Syndrome ▪ Heart failure ▪ Arrhythmias; atrial fibrillation ▪ Stroke/transient ischaemic attack (TIA) Classwork Resources BNF latest edition Disease Management, 3rd edition MCQs in Clinical Pharmacy Sample paper Hypertension Risk factors Aims of treatment Non-pharmacological treatment Treatment thresholds and targets Drug therapy Treatment approach for hypertension NICE guidelines, BNF Jones NR et al. Br J Gen Pract 2020;70:90-91  Drug classes for BP-lowering therapy European guidelines Consider transition to Loop Diuretic if eGFR is between 30-45 ml/min/1.73 m2. If eGFR 100kg Smoker 20-30 daily Diagnosis Acute MI (STEMI) with reduced LVEF (30%) seen on echo ▪ Risk factors ▪ What other information would you like to have? ▪ Initial management (Acute phase) ▪ Long-term management ▪ Monitoring requirements Case discussion 2 HS is a 60-year old male presenting to A&E with 2-day history of breathlessness while watching TV and noted to be previously short of breath on exertion but over 2 days there was a sharp worsening. Patient complains of moderate central chest pain, which was not radiating down to arm. He complains of nausea but denies any loss of consciousness, vomiting and palpitations. Patient experienced chills on day of admission but was not febrile on admission with no productive cough. PMH O/E Hypertension Pale, distressed, ECG showed poor R wave Diabetes mellitus progression but no ST segment elevation, sinus tachycardia, BP: 180/110 mmHg, HR: 114 bpm DH regular, respiratory rate: 35bpm, Sp02: 98%, amlodipine 5mg daily hs-TnT rise from 41 to 350 ng/L Mixtard 30/70 45U-15U Interventions FH PCI x 1 drug eluting stent in left anterior descending Father died age 65 due to MI artery SH Ex-smoker (20-30 daily); Diagnosis Obese; General manager NSTEMI ▪ Risk factors and lifestyle modifications ▪ What other information would you like to have? ▪ Aims of treatment ▪ Initial and long-term management plan ▪ Monitoring requirements ▪ Patient advice Case discussion 3 MZ is a 61-year old male presenting with central chest pain not related to physical exertion and occurring after meals. No sweating, shortness of breath or loss of consciousness. PMH SH Coronary artery disease Ex-smoker (stopped 10 years ago) Hypertension Diabetes mellitus O/E CABG carried out 10 years ago BP 140/80 mmHg Pulse 80 bpm, regular DH aspirin 75mg daily ECG shows no ST-segment elevation amlodipine 5mg daily bendroflumethiazide 5mg daily Diagnosis isosorbide mononitrate 60mg daily Unstable angina simvastatin 40mg daily Q1 Unstable angina: 1. is usually caused due to plaque rupture 2. is characterised by sudden worsening of previously stable angina 3. is precipitated by exertion and relieved by rest Answer : B Q2 In patients who had a coronary artery by-pass graft surgery: 1. a vein or artery graft is used to bypass the occlusion 2. reperfusion or revascularisation procedures cannot be undertaken 3. symptoms of angina do not occur Answer : D Q3 Investigations that should be requested in MZ on admission include: 1. percutaneous coronary intervention 2. blood glucose level What else? 3. serum electrolytes Answer : C Q4 On admission, a care plan for MZ should aim to: 1. provide symptom relief 2. reduce the risk of further cardiac events 3. provide antibacterial prophylaxis Answer : B Q5 For MZ, initial treatment should include: 1. starting warfarin 2. changing isosorbide mononitrate tablets to isosorbide dinitrate IV 3. starting enoxaparin sodium by SC injection Answer : C Q6 Therapy to be considered for long-term management in MZ includes: 1. digoxin 2. atenolol 3. perindopril Answer : C Q7 Nitrates: 1. are potent coronary vasodilators 2. reduce venous return 3. should not be used in the acute angina attack Answer: B Q8 Side-effects that may occur due to isosorbide mononitrate include: 1. postural hypotension 2. throbbing headache 3. flushing Answer : A Q9 Amlodipine: 1. should be avoided in MZ due to diabetes 2. reduces risk of myocardial infarction in unstable angina 3. may cause ankle swelling as a side-effect Answer : E Q 10 Simvastatin should be used with caution in patients with: 1. a history of liver disease 2. a high alcohol intake 3. high serum triglycerides Answer : B Q 11 Side-effects that may occur due to simvastatin include: 1. headache 2. nausea DDIs? 3. abdominal pain Answer : A Q 12 MZ should be advised to: 1. take simvastatin at night 2. report any muscle pain, tenderness or weakness 3. take simvastatin short-term until LDL-C level normalises Answer : B Other resources Reading material – VLE NICE guidelines (BNF) ESC guidelines Summary of Product Characteristics https://www.medicines.org.uk/emc  Other resources 2023 ESH Guidelines for the management of arterial hypertension. Available from: https://journals.lww.com/jhypertension/fulltext/2023/12000/2023_esh_guidelines_for_the_management_of_arte rial.2.aspx 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. Available from: https://academic.oup.com/eurheartj/article/42/34/3227/6358713 2019 ESC/EAS Guidelines for the management of dyslipidaemias. Available from: https://academic.oup.com/eurheartj/article/41/1/111/5556353 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. Available from: https://academic.oup.com/eurheartj/article/41/3/407/5556137?login=true 2023 ESC Guidelines for the management of acute coronary syndromes. Available from: https://academic.oup.com/eurheartj/article/44/38/3720/7243210 2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes. Available from: https://academic.oup.com/eurheartj/article/44/39/4043/7238227