case presentation

1. ACUTE Left Ventricular failure
SECONDARY TO IHD AND AKD
Bashar Talal Saad Mohammed
1st year M.Pharm
Pharmacy practice
Jss university
pharmacy college

2. Heart Failure

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

6. • 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

7. chronic alcoholic , not smoker
• Allergies:
NKA
• SHx:
NS

8. 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.

9. PROVISIONAL DIAGNOSIS
Acute Left Ventricular Failure and
secondary to IHD and AKI

10. CARDIOMYOPATHY
Signs of Heart Failure
• Pul. Edema
• S3 gallops
• Cool extremities
• Pleural effusion
• Cheynes stoke respiration
• Tachycardia
• Cardiomegaly
• Increased JVP
• Peripheral edema

11. 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

12. 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 .

13. LAB REPORTS
Hematology
Hb:
WBC:
DLC:
•N
•E
•B
•L
•M
Plt:
ESR:
13.4g%
7890 cells/ cumm
73.6 %
1.1 %
0.4 %
17.7 %
7.2 %
1.33 lakhs cells/ cumm
90 mm/hr
RBS
UREA
S.Cr
155 mg/dl
180 mg/dl
5.5 mg/dl
Electrolytes
Sodium
Potassium
Chlorides
Uric acid
132 mmol/ L
4.4 mmol/ L
105 mmol /L
10.3 mg/dl

14. TREATMENT CHART
Drug Dose R Freq. D
1
D
2
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 + +

15. 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

16. 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.

17. Drug Dose R Freq. D
1
D
2
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

18. 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

19. DAY 3 cont….
• Advice :
1-Repeat RFT , Chest x-ray and take nephrologist
opinion.
2- CBG every eight hours .

20. TREATMENT CHART
Drug Dose R Freq. D
1
D
2
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 + +

21. 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

22. 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 .

23. TREATMENT CHART
Drug Dose R Freq. D
1
D
2
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 + +

24. 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.

25. TREATMENT CHART
Drug Dose R Freq. D
1
D
2
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 + +

26. Discharge medications
Drug 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

27. Pharmaceutical
Care Plan

28. Subjective Evidence Objective Evidence
• Breathlessness
• edema
• crepitation's
•JVP
•ECG
•ECHO
•Blood Pressure
•Crepitation sound.
•S.Cr levels
•Urea levels

29. 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

30. 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.

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

32. Goals achieved
• Patient was symptomatically better by day 3
• Renal function was brought to near normal by
day 4.

33. 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.

34. 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

35. Patient Counseling

36. THANK YOU