Transcript Treatment in Cardiac disease - Barwon Division of General Practice

Treatment in Cardiac
disease
The PNs Roll
Dr. Sergio Diez Alvarez
Staff Specialist Physician
Armidale Hospital
Main Disorders
 Hypertension
 Congestive Cardiac Failure
 Ischemic Heart Disease
Case 1
 A 60-year-old woman with a 3-year history
of hypertension is seen for worsening
dyspnea and cough. She has had chronic
obstructive pulmonary disease (COPD)
since age 55. She now has dyspnea with
walking one-third of a block and a
persistent cough.
 Her hypertension has been managed with
diet and exercise.
 Physical exam reveals an anxious woman
with blood pressure 150/86 mmHg, pulse
80, respiratory rate 24, and weight 86 kg.
 O2 Sat: 88%
 GP has asked you to discuss some issues
with her about her current medical
conditions while she waits for her
appointment.
Issues
 Salt restriction
 Exercise
 Weight loss (BMI & waist circumference)
 Medication side effects
 Cardiovascular risk overall –
Microalbuminuria, ECG/Echo(LVH)
Congestive Cardiac Failure
Case 2
 A 60-year-old woman with a history of obesity,
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diabetes, dyslipidemia, and hypertension
presented to the GP rooms complaining of
fatigue, leg swelling and dyspnoea.
She was diagnosed with CCF and started on
Lasix 10mg daily at another GP practice.
Her diabetes had been managed with metformin
alone. Her diet is not good as she eats out a lot,
mainly at social gatherings.
BP controlled with ramipril.
Cholesterol controlled with Lipitor.
 On examination, blood pressure was
98/64 mmHg, pulse was 92/min, and
respirations were 20, weight 98kg.
 What advice can we give her with regards
to her CCF?
Issues
 Salt restriction
 Fluid restriction
 “the big Five” – digoxin, frusemide, βblocker, ACEI/ARB, spironolactone
 Cardiac Rehabilitation
 CCF is a syndrome - Manage the
Aetiology
Case 3
 A 61-year-old man with prior history of angina
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complaines of ongoing angina when he walks
especially uphill. He is scared of using his
anginine “too often as he may get addicted to it”.
He has hypertension and dyslipidaemia.
He had a stent put in 3 years ago for “a
blockage”
Smokes only when goes to the pub
Tries to exercise but worried about the chest
pain
 medications included:
 Diltiazem CD 180 mg daily
 Aspirin 100mg
 Anginine spray prn
 He is supposed to be on Simvastatin but it
gives him sore muscles so he only takes it
on the days he gets chest pain
 BP 140/90mmHg, HR 78/min, weight
102kg
 Laboratory investigations:
 Glucose 8.1mmol/l, cholesterol 4.6mmol/l
 What advice can you give him?
Issues
 Angina management in general
 Advice on lifestyle modifications
 Assess precipitants of angina
 Assess need for further investigations
 She was re-admitted with hyperglycemia as she
had run out of insulin
 During the 3-day hospital stay, she required 2 IU
of regular IV insulin per hour to maintain blood
glucose levels in the range of 9-11mol/l. She
was sent home on NPH insulin 25 IU twice daily
and metformin 500 mg also twice daily.
Pioglitazone was discontinued because of the
history of liver disease.
 She returned 10 days after discharge with
nausea, vomiting, polyuria, polydipsia, and
general malaise
 Diabetic ketoacidosis (DKA) was diagnosed and
the patient was started on an insulin drip. Two
days later the drip was discontinued and she
was started on Novomix 30 twice daily and
regular coverage. Despite increasing the daily
doses of insulin to 112 IU daily, her glucose
continued to increase into the range of 1215mmol/l and the acidosis worsened. She was
found to be suffering from DKA again with a
bicarbonate level of 12 mEq/dL and positive
ketones in blood.
 An insulin drip was started again and she was
transferred to the ICU. Over the next several
days, the drip was increased up to 12 IU per
hour . Blood glucose levels decreased slowly
into the 9mmol/l range and bicarbonate
normalized. After extensive discussions, it was
decided to start metformin 500mg bd despite the
past history of autoimmune liver disease. The
blood glucose continued to decrease and finally
stabilized in the range of 8-10mmol/l. The patient
was transferred to the regular floor after a total
of 9 days in the ICU.
 She is due for discharge, what regimen do you
use?