acute left ventricular failure secondary to ischemic heart disease and acute kidney injury

ACUTE Left Ventricular failure SECONDARY TO IHD AND AKD

Bashar Talal Saad Mohammed1st year M.PharmPharmacy practice

Jss university pharmacy college

Heart Failure

• Age: 56 years• Sex: male• Weight: 58 Kg• Unit: CCU• IP No: 87215

• Reasons for admission: C/O chest discomfort since 3 day ,

breathlessness since 4 day patient was apparently normal till past 4 days

sever breathlessness , chest pain central not radiating ,not associated with sweating and burning type .

• PMHx: No k/c/o HTN/DM No h/o IHD /fever / CO

chronic alcoholic , not smoker

• Allergies: NKA

• SHx: NS

General examination

• O/E no PICCLE• c/o breathlesness • BP: 120/70 mmHg Pulse: 90 BPM• CVS: S1S2 + • RS: B/L NVBS + B/L diffuse crepitation's +• CNS: NFND• JVP.

PROVISIONAL DIAGNOSIS

Acute Left Ventricular Failure and secondary to IHD and AKI

CARDIOMYOPATHYSigns of Heart Failure

• Pul. Edema• S3 gallops• Cool extremities• Pleural effusion• Cheynes stoke respiration• Tachycardia• Cardiomegaly• Increased JVP• Peripheral edema

DAY1

• c/o breathlessness SpO2 100% on NIV support• BP: 120/70 mmHg Pulse: 90 BPM• CVS: S1S2 + • RS: B/L NVBS + B/L diffuse crepitation's +• CNS: NFND• Creatinine : 5.5 mg/dl • GFR : 12.4 ml/min• I/O : 730.8 /1975 ml

DAY 1 cont…

• ADV: I/O chart , Urea, Serum Creatinine, Serum electrolytes, Urine routine, ECG, 2D-ECHO, CXR, ABG, nephrologist opinion.

• ADV continue fluid + dopamine + noradrenaline .

LAB REPORTSHematology

Hb:WBC:DLC:•N•E•B•L•MPlt:ESR:

13.4g%7890 cells/ cumm

73.6 %1.1 %0.4 %17.7 %7.2 %1.33 lakhs cells/ cumm90 mm/hr

RBSUREAS.Cr

155 mg/dl180 mg/dl5.5 mg/dl

Electrolytes

SodiumPotassiumChlorides Uric acid

132 mmol/ L4.4 mmol/ L105 mmol /L10.3 mg/dl

TREATMENT CHARTDrug Dose R Freq. D

1 D2

T.Aspirin 150mg PO 0-1-0 + +

T. Clopidogrel 75 mg PO 1-0-0 + +

T. Atorvastatin 20 mg PO 0-0-1 + +

T. Trimetazidin MR 35 mg PO 1-0-1 + +

Inj. Lasix 20 mg inj 1-1-0 + +

Inj. Heparin 5000 IU INJ 48 Hrs + +

Dopamine + noradrenaline inj 1-0-0 + +

DAY 2

• BP: 120/70 mmHg Pulse: 88 BPM• RS: B/L NVBS + B/L diffuse crepitation's +• FCBG: 250 mg/dl• SpO2: 86% on NIV support.• CVS: S1S2 +, no Murmurs• Neurologist opinion: acute kidney injury caused by Cardiogenic shock

advice for Antibiotics and continue Lasix 20 mg

DAY 2 cont….• Chest X-ray showing pulmonary edema.• Creatinine : 4.7 mg/dl.• GFR : 13.4 ml/min.• I/O : 1070/ 1300 ml • Added antibiotics and continue as chart.

Drug Dose R Freq. D1

D2

T.Aspirin 150mg PO 0-1-0 + +

T. Clopidogrel 75 mg PO 1-0-0 + +

T. Atorvastatin 20 mg PO 0-0-1 + +

T. Trimetazidin MR 35 mg PO 1-0-1 + +

Inj. Lasix 20 mg inj 1-1-0 +

Inj. ceftazidine + sulbactam 1.5 mg inj 1-0-1 +

Inj. Heparin 5000 IU INJ 48 Hrs + +

Dopamine + noradrenaline inj 1-0-0 + +

TREATMENT CHART

DAY 3

• BP: 100/60 mmHg Pulse: 83 BPM• RS: B/L NVBS + B/L decrease crepitation's +• FCBG: 170 mg/dl• SpO2: 86% on NIV support.• CVS: S1S2 + no Murmurs• Creatinine : 3.1 mg/dl• GFR: 21.6 ml/min• I/O : 1335/1240 ml

DAY 3 cont….

• Advice :1-Repeat RFT , Chest x-ray and take nephrologist opinion.2- CBG every eight hours .

TREATMENT CHARTDrug Dose R Freq. D

1 D2

T.Aspirin 150mg PO 0-1-0 + +

T. Clopidogrel 75 mg PO 1-0-0 + +

T. Atorvastatin 20 mg PO 0-0-1 + +

T. Trimetazidin MR 35 mg PO 1-0-1 + +

Inj. Lasix 20 mg inj 1-1-0 + +

Inj. ceftazidine + sulbactam 1.5 mg inj 1-0-1 +

Inj. Heparin 5000 IU INJ 48 Hrs + +

Dopamine + noradrenaline inj 1-0-0 + +

DAY 4

• BP: 100/70mmHg Pulse: 76 BPM• CVS: S1S2 +, no Murmurs• RS: B/L NVBS + B/L decrease crepitation's +• ADV: Treatment as per chart• FCBG :170 mg/dl• Creatinine : 2.2 mg/dl• GFR: 32.1 ml/min• I/O : 1850/1710 ml

DAY 4 cont….

• Nephrologist : ptz is stable , renal function are gradually return to normal.

• Ptz still need to repeat echo and chest x- ray for minotring .

• Advice to stop dopamin and adrenaline .

TREATMENT CHARTDrug Dose R Freq. D

1 D2

T.Aspirin 150mg PO 0-1-0 + +

T. Clopidogrel 75 mg PO 1-0-0 + +

T. Atorvastatin 20 mg PO 0-0-1 + +

T. Trimetazidin MR 35 mg PO 1-0-1 + +

Inj. Lasix 20 mg inj 1-1-0 + +

Inj. ceftazidine + sulbactam 1.5 mg inj 1-0-1 +

Inj. Heparin 5000 IU INJ 48 Hrs + +

DAY 5

• BP: 100/74mmHg Pulse: 72 BPM• CVS: S1S2 +, no Murmurs• RS: B/L NVBS +, crepts +• CBG: normal • Improvement of renal function .• ADV: Repeat urea, Creatinine, S/E• ADV: continue in physiotheraby.

TREATMENT CHARTDrug Dose R Freq. D

1 D2

T.Aspirin 150mg PO 0-1-0 + +

T. Clopidogrel 75 mg PO 1-0-0 + +

T. Atorvastatin 20 mg PO 0-0-1 + +

T. Trimetazidin MR 35 mg PO 1-0-1 + +

Inj. Lasix 20 mg inj 1-1-0 + +

Inj. ceftazidine + sulbactam 1.5 mg inj 1-0-1 +

Inj. Heparin 5000 IU INJ 48 Hrs + +

Discharge medicationsDrug Dose R Freq.

T.Aspirin 150mg PO 0-1-0

T. Clopidogrel 75 mg PO 0-1-0

T. Atorvastatin 20 mg PO 0-0-1

T. Trimetazidin MR 35 mg PO 1-0-1

Pharmaceutical Care Plan

Subjective Evidence Objective Evidence

• Breathlessness • edema • crepitation's •JVP

•ECG•ECHO•Blood Pressure•Crepitation sound. •S.Cr levels•Urea levels

Final Diagnosis

Based on subjective and objective evidence the patient was diagnosed with

ACUTE LEFT VENTRICAL FAILURE SECONDARY TO ISCHEMIC HEART DISEASE

AND ACUTE KIDNEY INJURY

Goals of Treatment For Heart Failure:

• Relieve symptoms of central and peripheral circulatory congestion

• Improve quality of life • Reduce neurohormonal

activation • Minimize or prevent acute

CHF exacerbations • Slow progression of CHF • Increase survival • Maintain appropriate blood

pressure and lipid values. • Reduce mortality

For Renal injury:• Gradually relieve of

renal function • Prevent symptoms of

renal failure • Prevent progresses of

renal failure.• Prevent long-term

complication . • Maintain a flexible

and normal lifestyle.

Treatment Options

For Heart Failure• ACE inhibitors / ARB’s• Diuretics• Beta blockers• Spironolactone • Digoxin / Dopamine

Goals achieved • Patient was symptomatically better by day 3• Renal function was brought to near normal by

day 4.

Problems identified• Cardiac enzymes were not done (CKMB).• CBG was abnormal and no treated or advice

Glycosylated Hb.• Platelet and RBC were be Decreased and no

treated.

Monitoring Parameters

Disease Related• ECG• ECHO• Chest X-ray• Blood pressure• Fluid intake• Electrolytes • Vital signs • Renal function test• Blood Glucose levels

Drugs Related• Blood Pressure• Blood Glucose levels• Electrolytes• Renal function test

Patient Counseling

THANK YOU