Download Exam C 2009 - Pharm D Notes

PHA 5592 Pharmaceutical Care for Patients with Cardiac Disorders
Fall 2009
Exam 3
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Instructions:
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This is a 2 hour open book exam. Please document your answer as directed to each question/issue in
a brief and clear response. Your responses must by unambiguous and answer the question presented.
This exam is worth 100 points. Point values for each specific question are indicated.
Please note that laptops or handhelds (e.g. Palm Pilot®, Handspring®, Blackberry®) are permitted
during the exam. However, none of these devices should be connected to the internet during the
exam (this includes cell phones with internet capabilities). Also, it is the student’s responsibility to
ensure that they have adequate battery power for their laptop during the exam as there may not be
enough power outlets available at each examination site.
Chronic Stable Angina (20 points total)
Questions 1--‐4 pertain to the following case.
AC is a 62 year old man with hypertension, dyslipidemia, and type 2 DM. He is referred to
cardiology clinic by an urgent care physician for assessment of his chest pain. He has a 40 year
pack--‐year smoking history. His medications are listed below:
Metformin (Glucophage) 500 mg BID
Aspirin 81mg daily
Simvastatin (Zocor) 10 mg qnight
Lisinopril (Zestril, Prinivil) 20 mg daily
Atenolol (Tenormin) 50mg daily
He weighs 200 lbs; BP is 114/60 mm Hg, and his HR is 85 beats/min.
Labs:
TC
197 mg/dl
ALT24 IU/l
LDL
120 mg/dl
HgA1c 6.9 %
HDL 30 mg/dl
Glucose100 mg/dl
TG
290 mg/dl
1. Which of the following chest pain scenarios would be most indicative of stable angina
and therefore would not require immediate evaluation for ACS? (2.5 pts)
a. Chest pain occurring on wakening in the morning
Chest pain occurring in the morning without any activity may be an acute
coronary syndrome in progress
b. Shortness of breath and chest burning/tightness while climbing 2 flights of
stairs Correct answer that fits description of stable angina. Symptoms occur
with exertion in a predictable fashion.
c. Chest pain with radiation to left arm while a passenger in a car
Chest pain occurring without increased oxygen demand may indicate an ACS
(MI etc)
d. Chest pain occurring while relaxing watching television.
Chest pain at rest is more consistent with unstable angina pectoris
2. BR undergoes a treadmill exercise test and develops ECG changes indicative of ischemia.
Which of the following ECG changes is most likely in a patient experiencing myocardial
ischemia? (2.5 pts)
a. Prolonged PR interval
Incorrect, Indicative of first degree AV block
b. Prolonged QT interval
Incorrect, Indicative of prolonged repolarization of the ventricle tissue
c. ST--‐Segment depression
Correct, ST- segment depression is indicative of ischemia
d. Q waves
Incorrect, the vast majority of abnormal Q waves are due to myocardial
infarction
3. Which of the following is the best short--‐term goal for BR for treatment of his angina?
(2.5 pts)
a. Optimize drugs to prevent angina symptoms with daily activity
The best answer, There is room to increase his atenolol to lower his resting heart rate and
you could add a nitrate for symptomatic relief.
b. Increase his simvastatin to obtain an LDL goal less than 100 mg/dl
Incorrect, Decreasing his LDL is a secondary goal but relieving the anginal symptoms are
top priority.
c. Increase his lisinopril to lower his systolic blood pressure to goal
Incorrect, The patient’s blood pressure is within goal range.
d. Increase his metformin to lower his HgA1c
Incorrect, HgA1c is not associated with anginal symptoms and his HgA1c is already in an
acceptable range.
4. It is decided that a nitrate will be added to BR’s medicine regimen. Which of the
following nitrate regimens is most appropriate of BR? (2.5 pts)
a. Isosorbide dinitrate (ISDN) 10mg po every 6 hours
Incorrect, ISDN every 6 hours does not allow for a nitrate free interval
b. Isosorbide mononitrate (Imdur) 30mg po daily
Best answer, this dosage form lasts about 12 hours and allows a nitrate free interval
c. Isosorbide mononitrate (Ismo) 20 mg po at bedtime
Incorrect, This dosage form is usually given bid
d. Nitroglycerin ointment ½ inch to chest every 8 hours
Incorrect, Usually reserved for patients unable to tolerate po, also every 8 hour dosing
does not provide a nitrate free interval
Questions 5--‐6 pertain to the following case.
AC develops angina when he walks more than one block, despite maximal medical therapy
consisting of the following therapy:
Isosorbide mononitrate (Imdur) 90mg daily
Metoprolol ER (Toprol XL) 100mg daily
Amlodipine (Norvasc) 10mg daily
Atorvastatin (Lipitor) 40 mg daily
Aspirin 81mg po daily
Ramipril (Altace) 5mg daily
He recently quit smoking and enrolled in an exercise program to improve his symptoms. His
heart rate is 56 beats/minute at rest and 64 beats/min with exercise. His BP is 103/64 mm HG.
5. Which of the following is the best plan for JM? (2.5 pts)
a. Increase the metoprolol to 200 mg daily
Incorrect, his resting and exercise hear rate are acceptable and increasing the drug may
not add to exercise capacity
b. Suggest that he quits the exercise program to avoid the symptoms
Incorrect, ACC/AHA guidelines encourage exercise 7 days per week in stable angina
patients
c. Add Warfarin 5 mg daily
Incorrect, the addition of warfarin would increase risk of bleeding and there is no
evidence that this would decrease frequency of anginal symptoms
d. Add sublingual nitroglycerin 0.4 mg before exercise
Correct, Prophylactic sublingual nitrates may allow JM to participate in his exercise plan
6. JM understands that chronic stable angina is a manifestation of an imbalance of
myocardial supply and demand. However, he is not sure why he takes metoprolol.
Which of the following is the best explanation for him taking metoprolol? (2.5 pts)
a. Metoprolol decreases both myocardial supply and demand
Incorrect, beta blockers have no significant effects on coronary blood flow to the
myocardium
b. Metoprolol decreases myocardial supply
Incorrect, beta blockers have minimal effects on coronary blood flow to the myocardium
c. Metoprolol decreases LDL levels which reduces the risk for atherosclerotic lesions
Incorrect, positive LDL findings have not been associated with beta blockers and they are
suspected of having detrimental lipid side effects in certain patients.
d. Metoprolol decreases myocardial demand
Correct, Beta blockade reduces myocardial oxygen demand
7. A 35 year old man enters your clinic with a diagnosis of variant/prinzmetal angina. He
has a non significant past medical history and jogs 3 miles on 5 days per week. Which of
the following is the best therapy for S.D.’s angina? (2.5 pts)
a. Amlodipine daily
Correct, Calcium channel blockers are drugs of choice for variant/prinzmetal angina
b. Aspirin daily
Incorrect, will not reduce the risk of vasospams
c. Ranolazine BID
Incorrect, Indicated for angina refractory to maximum traditional therapy (BB, CCB’s,
Nitrates, etc)
d. Metoprolol daily
Incorrect, may worsen symptoms
8. Which of the following medication combinations should not be used together? (2.5 pts)
a. metoprolol – verapamil
b. verapamil – nitroglycerin
c. nitroglycerin – sildenafil
d. sildenafil – ranolazine
e. A and C
Metoprolol and verapamil should not be used concomitantly since both are potent negative
inotropes and chronotropes and can cause bradycardia and heart failure. Nitroglycerin and
sildenafil must be avoided due to the potential for profound, protracted bradycardia.
Acute Coronary Syndrome (32 points total)
MJ is a 61 yo WM with a hx of coronary artery disease (CAD) status post CABG. He
presented to the emergency department with complaints of substernal crushing chest pain
radiating to the jaw. ECG revealed 3 mm ST--‐segment elevation in leads I and V2--‐V4. CXR
revealed pulmonary congestion.
PAST MEDICAL HISTORY: CAD, CABG in 1995, diverticulitis, chronic renal insufficiency,
hypothyroidism, obstructive sleep apnea, hyperlipidemia, chronic Afib, osteoarthritis.
PAST SURGICAL HISTORY: 2 vessel coronary artery bypass graft.
ALLERGIES: Sulfa.
SOCIAL HISTORY: He is divorced, lives alone. Tobacco: He has a 45--‐year history of smoking
1/2 pack per day. He is currently smoking about 3 cigarettes a day, last 3 days ago. Alcohol:
None. Illicit Drugs: None.
FAMILY HISTORY: Positive for cancer.
REVIEW OF SYSTEMS: Positive for shortness of breath, dyspnea, and chest pain.
PHYSICAL EXAMINATION: BP 160/91, pulse 105, respirations 20, temperature 95.2, and
saturating 95% on 2 liters of oxygen.
HOME MEDICATIONS: warfarin 5 mg po daily, aspirin 81 mg po daily, metoprolol 25 mg bid,
atorvastatin 40 mg po daily, isosorbide mononitrate 60 mg po daily, and furosemide 40 mg
daily
LABORATORIES:
normal values
POTASSIUM (K)
4.60 MMOL/L
3.50 --‐ 5.00
BUN
27.0 MG/DL
8.0 --‐ 20.0
CREATININE
1.5 MG/DL
0.6 --‐ 1.3
CALCIUM
8.7 MG/DL
8.4 --‐ 10.2
CREATINE KINASE
126 IU/L
25 --‐ 260
MASS CKMB
1.90 NG/ML
<=4.90
RELATIVE INDEX
1.5
<=2.0
TROPONIN I ULTRA
2.12 NG/ML
<=.06
HEME PANEL: Within normal limits
INR
1.7
9. You are the pharmacist in the emergency department of a small rural hospital. The
attending physician decides to use a fibrinolytic on this patient. Should the physician
choose this therapy in MJ? Justify your answer. (6 pts, 3 pts for yes and 3 pts for
rationale. They do not have to mention monitoring for credit as it is not specifically
mentioned in the question).
Yes, fibrinolytic therapy should be used in this patient because he is having an ST
segment elevation MI. His blood pressure is below the range to be contraindicated
and the warfarin is not an absolute contraindication. Bleeding must be closely
monitored.
10. According to ACC/AHA guidelines what is the target “door to needle” time for
administration of thrombolytic agents? (4 pts)
Less than 30 minutes
11. If MJ were started on heparin, what monitoring parameters would you follow with your
team? (5 pts)
a.
b.
c.
d.
INR (Goal 2, range 1.5--‐2.5), platelets
INR (Goal 2.5 range 2--‐3), Hgb/HCT
aPTT (Goal 2 x control), platelets, Hgb/HCT
aPTT (Goal 3 x control), Platelets, Hgb/HCT
The following day after being stabilized, MJ is transferred to a larger hospital with a cath lab.
He undergoes cardiac catheterization and the left anterior descending (LAD) artery had a
proximal occlusion. The patient had a Cypher® (sirolimus--‐eluting stent) placed in the LAD.
12. Given this information, how long would you recommend MJ receive clopidogrel? (5 pts)
a.
b.
c.
d.
6 months
3 months
1 month
12 months
The team asked for you to review MJ’s medication profile. His post--‐MI echo revealed an EF
30%. His current vital signs: HR 66, BP 134/85, T 98.6F, RR 14. No changes in renal or liver
function. His medication profile is as follows: Clopidogrel 75 mg daily warfarin 5 mg po daily,
aspirin 160 mg po daily, metoprolol 25 mg bid, atorvastatin 40 mg po daily, isosorbide
mononitrate 60 mg po daily, and furosemide 40 mg daily.
13. What recommendation would you make to the team? (5 pts)
a.
b.
c.
d.
No changes are needed
Initiate Lisinopril 10 mg po daily
Discontinue coumadin due to increase risk of bleeding
Increase aspirin to 650 mg po daily
14. Which of the following medications should be recommended as initial treatment if MJ
complains of joint pain? (5 pts)
a.
b.
c.
d.
Celecoxib 200 mg daily
Ibuprofen 200 mg TID
Acetaminophen 650 mg q6 hours
Tramadol 50 mg QID
CABG and Postoperative Care (14 points total)
15. HG is a 62 yo WM with past medical history of MI (2 years ago), hypertension, EF=30%.
His current medications include metoprolol succinate 100 mg daily, lisinopril 20 mg
daily, furosemide 20 mg twice daily, ECASA 81 mg daily and atorvastatin 10 mg daily.
Weight is 90kg. All labs are within normal limits. He is scheduled for coronary artery
bypass grafting (CABG) in 2 weeks. His surgeon is concerned about the risk of post--‐
operative atrial fibrillation. What medication is the drug of choice to prevent this
arrhythmia? Please give the specific dose of the medication and length of therapy. (6
pts)
Amiodarone 400mg PO BID x 1 week prior to surgery, continue IV through surgery and
until PO meds started. Continue 400 mg PO BID once PO meds started and continue
through discharge as long as no afib has occurred. If pt had afib post--‐op, continue 400
mg BID x 21 days total, then change to 200 mg daily for a total of 30--‐60 days of
amiodarone therapy.
16. When HG returns from surgery, his labs are as follows:
WBC 14
Hgb 9.6
HCT 28
PLT 176
Cl 114
HCO3 14
BUN 16
Na 137
K 3.8
SrCr 1.2
ABG=7.42/37/88/14/96%
Calculate the anion gap and show calculations. (4 pts)
Anion Gap = Na--‐(Cl+HCO3)
Anion Gap =137--‐(114+14) =9
17. Based on the anion gap, the physician would like to give Na bicarbonate. Calculate the
bicarbonate deficit in meq. Show your calculations. (4 pts)
Bicarbonate deficit = ABW x 0.6 x 0.5 (22--‐HCO3)
Bicarbonate deficit = 90kg x 0.6 x 0.5 (22--‐14) = 216 meq
Cardiac Transplant (16 points total)
UH is a 46 yo WF that is 14 months post cardiac transplant. She has come to the pharmacy
today to pick up her refill of cyclosporine.
18. Name three adverse effects of cyclosporine. (6 pts)
Any three of the following: acne, nephrotoxicity, hirsutism, gingival hyperplasia,
hypertension, bone pain, gingivitis, electrolyte imbalances, infusion reaction, tremor,
neurotoxicity
19. UH reports that these cyclosporine capsules are different than those she has always
taken. Upon investigation, it is found that her prescription has been filled with the
other cyclosporine generic formulation. The best resolution to this mistake is: (4 pts)
a. Allow the patient to take these instead of the cyclosporine she has previously
used as these are interchangeable generic forms of cyclosporine.
b. Allow the patient to take this cyclosporine and advise her to have her
cyclosporine levels checked in 2 weeks.
c. Exchange the new generic for the previous correct formulation.
d. Continue the new generic formulation, but adjust the dose to account for the
differences in bioavailability and check a cyclosporine level in 1 week.
20. While UH is waiting for her prescription, she mentions she has been gaining weight
recently and feels like she can’t get her breath when she is walking. She wonders if she
needs a “water pill” to help with her swollen ankles. What very serious complication
could this patient be experiencing based on the symptoms listed as well as her history?
(3 pts)
Transplant rejection
21. What procedure/test can be used to verify this potential complication? (3 pts)
Endomyocardial biopsy
Evaluating Medical Literature (18 points)
3687 patients with a previous MI were randomized to receive treatment with a novel
antiplatelet agent (n=1840) or placebo (n=1847). All patients also received aspirin 81 mg/ po
daily. The patients were followed for 5 years for the composite endpoint of death due to
cardiovascular causes, recurrent MI, or stroke. At the end of 5 years, the following was found;

the composite endpoint occurred in 8.2% of patients receiving placebo plus aspirin and
in 5.9% of patients receiving the novel antiplatelet agent plus aspirin.

Major bleeding was increased in the patients receiving the novel antiplatelet drug plus
aspirin (3.4%) as compared to patients receiving placebo plus aspirin (2.1%).
22. For the composite endpoint, calculate: 1. relative risk(RR) 2. relative risk reduction(RRR)
3. absolute risk reduction(ARR) and 4. number needed to treat (NNT). Show your
calculations. (3 points each, 12 points total)
Relative Risk (RR) (3 pts)
RR = 109/1840 divided by 152/1840 = 0.72
or you can compare the percentages
RR = 0.059 / 0.082 = 0.72
Relative Risk Reduction (RRR) (3 pts)
1 – RR = 1 – 0.72 = 0.28 or a 28% RRR
Or you can use the long calculation
0.082 – 0.059 divided by 0.082 = 0.28 or 28% RRR
Absolute Risk Reduction (ARR) (3 pts)
0.082 – 0.059 = 0.023 = 2.3%
Number Needed to Treat (NNT) (3 pts)
NNT = 1 / ARR = 1 / 0.023 = 43.5 or 44 patients need to be treated with the novel
antiplatelet to prevent 1 composite endpoint
23. For major bleeding, calculate the NNH. Show your calculations.(3 pts)
Number Needed to Harm (NNH)
First calculate ARR in bleeding = 0.021 – 0.034 = --‐0.013 (take absolute value) so the
absolute difference in bleeding between the 2 groups was 1.3%
NNH = 1/ARR = 1/.013 = 76.9 or 77 patients. For every 77 patients treated with the
novel antiplatelet drug, 1 will have a major bleed.
24. In your opinion, do the benefits of the novel antiplatelet drug outweigh the risks? (3pts)
The students should generally discuss that the NNT of 44 is lower than the NNH of
77, which does favor treatment. However, if your student feels that the risks still
outweigh the benefit, and if their reasoning is rationale, that decision is also okay.
The purpose is to get them comparing NNTs and NNHs for an intervention.