Medications after Discharge

Chest Pain

CP is a 64-year-old male who presents to the emergency department (ED) via ambulance for chest pain. He was out shoveling snow from his driveway when he developed left anterior chest pain, pressure-type, radiating to his jaw and shoulder. Despite the cold weather, he was sweating. He also noted palpitations and shortness of breath, although he thought it was just because he was “a little out of shape.” He was afraid that something was wrong, so he asked his wife to call 911.

 

Past Medical History

• Hypertension
• Hyperlipidemia
• Diabetes mellitus
• Gout Medications
• Hydrochlorothiazide, 25 mg once daily
• Allopurinol, 300 mg once daily

 

Social History

• Retired factory worker
• Smokes one pack of cigarettes per day
• Drinks about six beers per day (sometimes more)

 

Physical Examination

• Well-developed obese man in moderate distress
• Height: 69 inches; weight: 252 lbs.; blood pressure: 172/110; pulse: 92; respiration rate: 16; temperature: 98.7 °F
• Lungs: Scattered bilateral wheezes
• Heart: Regular with grade II/VI systolic murmur
• Extremities: No edema

 

Labs and Imaging

• Complete blood count with mild leukocytosis (WBC 12.9k)
• Potassium: Low at 2.9 mEq/L
• Glucose: 252 mg/dL
• Troponin I: 1.7 ng/L
• Uric acid: 11.1 mg/dL
• EKG: ST segment depression with T-wave inversion over lateral leads; no pathologic Q waves Next Steps
• CP’s admitting diagnoses are non-ST segment elevation acute coronary syndrome, hypertension, diabetes mellitus, obesity, alcohol abuse, hyperuricemia, and smoker

 

Discussion Questions

1. What medications should be instituted for CP?
2. What medications should be continued after discharge?
3. What lifestyle modifications can be recommended for CP?

Discussion Questions

1. What medications should be instituted for CP?

For CP, immediate medical management in the emergency department for non-ST segment elevation acute coronary syndrome (NSTEMI) should include:

• Antiplatelet therapy: Aspirin 325 mg should be given immediately. Additionally, a P2Y12 inhibitor such as clopidogrel, ticagrelor, or prasugrel should be initiated.
• Anticoagulation: Heparin or low molecular weight heparin (e.g., enoxaparin) should be administered.
• Nitrates: Nitroglycerin can be given for chest pain relief, either sublingually or via IV infusion.
• Beta-blockers: Metoprolol or another beta-blocker can be given to reduce myocardial oxygen demand unless contraindications exist.
• Statins: High-intensity statin therapy, such as atorvastatin 80 mg, should be started.
• ACE inhibitors or ARBs: Lisinopril or losartan can be started, especially considering his hypertension and diabetes.
• Potassium replacement: Potassium chloride should be administered to correct his hypokalemia.

2. What medications should be continued after discharge?

After discharge, CP should continue with:

• Antiplatelet therapy: Aspirin 81 mg daily indefinitely, and a P2Y12 inhibitor (e.g., clopidogrel or ticagrelor) for at least 12 months.
• Beta-blocker: Continue with metoprolol or another beta-blocker as prescribed in the hospital.
• ACE inhibitors or ARBs: Continue with lisinopril or losartan to manage hypertension and provide renal protection in diabetes.
• Statins: Continue with atorvastatin 80 mg daily or another high-intensity statin.
• Diabetes management: Adjustments in diabetes medications might be necessary; consider adding metformin or insulin therapy as per his blood glucose levels.
• Uric acid-lowering therapy: Continue allopurinol 300 mg daily.
• Antihypertensive: Hydrochlorothiazide 25 mg daily should be re-evaluated; consider other antihypertensive medications if needed.
• Potassium supplementation: Continue oral potassium supplements as required to maintain normal levels.

3. What lifestyle modifications can be recommended for CP?

CP should be advised to make significant lifestyle changes to reduce his cardiovascular risk:

• Smoking cessation: Enroll in a smoking cessation program and consider nicotine replacement therapy or medications like varenicline.
• Alcohol reduction: Limit alcohol intake to no more than two drinks per day, with a goal of further reduction to improve overall health.
• Diet: Adopt a heart-healthy diet, such as the DASH (Dietary Approaches to Stop Hypertension) diet or a Mediterranean diet, which emphasizes fruits, vegetables, whole grains, lean proteins, and healthy fats.
• Exercise: Engage in regular physical activity, aiming for at least 150 minutes of moderate-intensity aerobic exercise per week, with physician approval and guidance.
• Weight management: Aim for gradual weight loss to achieve a healthier BMI, targeting a weight loss of 1-2 pounds per week.
• Gout management: Avoid foods high in purines (e.g., red meat, organ meats, shellfish) and stay hydrated to help manage uric acid levels.
• Diabetes management: Follow a diabetes care plan, including monitoring blood glucose levels, adhering to prescribed medications, and maintaining a balanced diet.
• Regular follow-up: Ensure regular follow-up visits with primary care and cardiology for ongoing management and adjustment of medications as needed.