MI (CASE # 1) Mr. X is a 66-year-old white male who presented to his local physician with complaints of chest pain.

He described the pain as sharp, aching, and non-radiating. The pain, which he has had for the past few weeks, has occurred mainly during his daily walk and is usually relieved when he stops to rest. Past medical history: hypertension, PUD, CAD, asthma Family history: Father died of a stroke at 86; mother died at age 82 with diabetes mellitus and heart failure; sister died of MI at 52 Social history: Smokes 1 pack per day 40 years; drinks alcohol socially 1-2 times a week Medications: Risek 20 mg daily Ascard 75 mg daily Diuza 25 mg daily Vital signs: BP 148/92; HR 82; RR 18; height 72; weight 200 lbs Labs: (fasting) total cholesterol 226 mg/dL; TG 110 mg/dL; HDL 38 mg/dL; LDL 166 mg/dL; Chem 12-within normal limits ECG: Normal (patient currently pain free)
1. How would you classify Mr. Smith's chest pain?

2. Which counseling points should be made to a patient being prescribed SL NTG?

3. Which -blockers you should you suggest to the clinician (state starting and target dose) also justify your choice?

Key: 1. Angina is considered stable if symptoms have been occurring for several weeks without worsening, it lasts < 30 minutes, and it is relieved by rest or SL NTG. 2. Take at the first sign of chest pain; if chest pain is unrelieved, seek emergency medical attention. 3. Selective beta blockers such as metoprolol, bisoprolol or atenolol. Selective beta-1 receptor blocker has lower affinity for beta-2 receptor which has bronchodiatory effect. Its blockade by non-selective beta blockers can precipitate exacerbations.

MI (CASE # 2) S. P. is a 45-year-old marathon runner. He presents to the emergency department with complaints of chest pain during his morning run. Family history: His father died of a myocardial infarction at age 48. Past medical history: angina, hyperlipidemia, and hypertension. Medications: Acard 75mg PO OD Lipitor 20mg PO h.s Nifidipine SR 30mg OD clonidine.

Labs: CBC and Chem-7 are within normal limits. Vital signs: HR is 52 and BP is 170/100 ECG: consistent with acute ischemia.
Dx: Acute MI

1. Is IV metoprolol followed by PO metoprolol is the appropriate intervention with patient condition? 2. Which class of Nifidipine belongs and how it is different from other CCBs? 3. What counselling should the patient receive regarding the side-effects and food interactions of statins?

Key: 1. One of the contraindications to -blockade is a HR < 55 bpm. Because S. P. has an HR of 52 bpm. 2. Belongs to Dihydropyridines class of CCBs. It block slow calcium channels in a dose-dependent fashion greater selectivity for vascular smooth muscle than for the myocardium, making them more potent vasodilators than either other two classes. 3. Instruct patient to report signs/symptoms of muscle pain, tenderness or weakness. Drug may cause diarrhea. Avoid taking large amount of grape-fruit.

MI (CASE # 3) Mr. FG is a 69-year-old retired school teacher who was admitted to the emergency department complaining of severe chest pain after climbing stairs at his daughters house. In the ambulance he is administered aspirin 300 mg. On arrival at hospital and subsequent examination and review by the admitting doctor the following information is obtained.
Past medical history: Hypertension (10 years). Type 2 diabetes mellitus (recently diagnosed, currently diet controlled). He has osteoarthritis of the knee. Family history: Father died following a myocardial infarction at 60 years of age. No maternal history of cardiovascular disease.

Medications history:
Diclofenac MR tablets 75 mg B.D Adalat LA tablets 20 mg B.D

Both were stopped on admission. Signs and symptoms on examination

Vital signs: Temperature 36.4C, B.P 160/80 mmHg, HR: 75 bpm, regular, RR 15 breaths per minute ECG: reveals ST elevation of 3 mm in the inferior leads.
Diagnosis: A preliminary diagnosis of myocardial infarction is made.

1. Enumerate the standard management guidelines for Acute MI, What is the dosing protocol for SL NTG? 2. What further diagnostic and biochemical tests should be ordered to help confirm the diagnosis? 3. What lifestyle modifications are appropriate for this patient?

Key: 1. Maintain cornory blood flow by SL NTG a. Maintain cornory blood flow by SL NTG b. Relief pain: Nalbuphine, Ketorelac or tramadol c. Antiplatelet therapy : Asprin 300mg SL , Clopidogrel 300 mg PO or with Enoxaprin d. Reduce myocardium work load by appropriate beta blocker 0.3-0.6 mg every 5 minutes for maximum of 3 doses in 15 minutes; may also use prophylactically 510 minutes prior to activities which may provoke an attack. 2. Serum electrolytes, cardiac troponins, BUN, sr creatinine. 3. Instruct patient to report signs/symptoms of muscle pain, tenderness or weakness. Drug may cause diarrhea. Avoid taking large amount of grape-fruit.

CHF (CASE # 1)
Patient Name: JJ, Age: 64, Sex: Male, Height: 5'11, Weight: 185 lbs Diagnosis: Myocardial infarction (2008), Hypertension, Heart failure, Hyperlipidemia

Vital signs: Temperature 36.4C, B.P 145/90 mmHg, HR: 88 bpm, regular ECG: showed LVEF 30% Labs: Total cholesterol: 160 mg/dL, LDL cholesterol: 95 mg/dL, HDL cholesterol: 50 mg/dL,
Triglycerides: 100 mg/dL, Serum potassium: 2.0 mEq/L

Medications history:
Lanoxin 0.125 mg 1 tab OD Lasix 40 mg 1 tab q am KCl 20 mEq 90 1 tab q am Zocor 40 mg 90 1 tab qhs EC aspirin 325 mg 90 1 tab q am Plavix 75 mg 1 tab q am Carvedalol 25mg B.D

1. What are the major adverse effects of lanoxin? 2. How carvedalol is preferred over other beta-blockers in this patient? 3. What are the non-pharmacological management options for CHF? Key:

1. Major adverse effects involve three systems: Cardiovascular (cardiac arrhythmias, bradycardia, and heart block) Gastrointestinal (anorexia, abdominal pain, nausea, and vomiting) Neurological (visual disturbances, disorientation, confusion, and fatigue)
2. Carvedilol exhibits a more pronounced BP lowering effect as a consequence of its 1-and 1-receptor blocking activities. carvedilol may provide additional antihypertensive efficacy 3. Dietary modifications such as sodium and fluid restriction, risk factor reduction including smoking cessation, supervised regular physical activity. Patient education regarding monitoring symptoms, dietary and medication adherence.

CHF (CASE # 2)
Patient Name: AB, Age: 71, Sex: Fenale, Height: 5'4", Weight: 150 lbs Diagnosis: Heart failure, Hypertension , Type 2 diabetes mellitus (recently diagnosed) Other complains: Dry cough

Vital signs: Temperature 36.4C, B.P 130/85 mmHg, HR: 80 bpm, regular, Echocardiogram: showed LVEF 25% Labs: Total cholesterol: 160 mg/dL, LDL cholesterol: 95 mg/dL, HDL cholesterol: 50 mg/dL,
Triglycerides: 100 mg/dL, Serum potassium: 2.0 mEq/L, Serum digoxin concentration: 0.8 ng/mL

Medications history:
Lanoxin 0.125 mg 1 tab qd Furosemide 80 mg 1 tab q am Zestril 20 mg 1 tab q am Toprol-XL 50 mg 1 tab qd Naproxen 500 mg 1 tab bid

1. As this patient has type 2 diabetes mellitus, Clinician decide to start oral hypoglycemic agent. Which drug/drug class would you suggest to clinicians (also justify your suggestion)? 2. What are the adverse effects of ACEIs? 3. Enumerate the classes of drugs that reduce preload and/or afterload.

Key: 1. Metformin and Sulfonylurea are relatively save Thiazolidinediones are not preferred and they are contraindicated in HF. Thiazolidinediones both increase the risk of developing new-onset HF and exacerbate existing HF. 2. Hypotension, Dizziness, Renal insufficiency, Cough, Angioedema, Hyperkalemia, Rash, Taste disturbances. 3. Preload reducers: Diuretics, Aldosterone antagonist, Nitrates. Afterload reducers: Vasodilators. Both: ACEIs, beta blockers.

CHF (CASE # 3) A 54-year-old African American man recently received a diagnosis of nonischemic cardiomyopathy (Ventricular hypertrophy). Today, he presents with fatigue, shortness of breath on exertion and low-grade fever. On physical examination, the patient has no wheezes, or crackles, and he denies productive Cough, chest pain, or palpitations.
Medical history: COPD and HTN, DM type II.

Labs: chemistry panel and complete blood cell count are within normal limits. Medications:
Salmeterol one inhalation two times/day Fluticasone 88 mcg inhaled two times/day Furosemide 80 mg two times/day Enalapril 20 mg two times/day Spironolactone 25 mg/day Metformin 850mg

1. What is the advantage of Eplerenone over spironolactone? 2. What are the Standard HF Therapies and Alternative/Adjunctive Therapies? 3. What are the detrimental effect of compensatory cardiomyopathy? 4. What is the mode of action of aldosterone antagonist? 5. Which adverse effect of metformin is important in patient with CHF?

Key: 1. Eplerenone is selective for the mineralocorticoid receptor and hence does not exhibit the endocrine adverse-effect profile commonly seen with spironolactone. 2. Standard HF Therapies: ACEIs, ARBs, Beta-Blockers Alternative/Adjunctive Therapies: Angiotensin receptor antagonist, Hydralazine, Digoxin 3. Diastolic dysfunction Systolic dysfunction Increased risk of myocardial ischemia Increased arrhythmia risk 4. Lactic acidosis

ARRHYTHMIA (CASE # 1) A 16-year-old girl is brought to the Accident and Emergency Department by her mother having collapsed at home. As a baby she had cardiac surgery and was followed up by a paediatric cardiologist until the age of 12 years, when she rebelled. She was always small for her age and did not play games, but went to a normal school and was studying for her GCSEs. There are cardiac murmurs which are difficult to characterize. Examination: she is ill and unable to give a history, Vital Signs: HR: 160 bpm (regular), BP: 80/60 mmHg E.C.G: broad complex regular tachycardia which the resident medical officer (RMO) is confident is an SVT.

1. What pharmacological treatment options are available for Supraventricular tachycardia? 2. Classify arrhythmias according to ventricular rate and anatomic location? 3. Name the classes of anti-arrhythmic drugs? Key:

1. -blockers (esmolol, metoprolol, propranolol, others) and Calcium channel blockers (diltiazem, verapamil) 2. Ventricular rate Bradyarrhythmias: Heart rate < 60 beats per minute (bpm). Tachyarrhythmias: Heart rate > 100 bpm. Anatomic location Supraventricular arrhythmias and Ventricular arrhythmias 3. Class Ia, Ib, Ic ( sodium channel blocker) Class II (beta blockers) Class III ( potassium channel blockers) Class IV ( Calcium channel blocker)

ARRHYTHMIA (CASE # 2) XY is a 77-year-old Asian female who approximately 1 month ago presented to the emergency department with complaints of SOB, palpitations, fatigue, lightheadedness, and weakness of unspecified duration. She was found to be in AF with a ventricular rate of 130 bpm. Diltiazem was initiated to control her ventricular rate with good response, and IV heparin for bridging plus long-term warfarin was initiated for stroke prevention. She presents today in the cardiology clinic for follow-up. She states she has been compliant with her medications, still feels tired, and occasionally notices she has a fast heart rate. Medical history: AF, HTN, Heart failure (HF) (EF 50%), Glaucoma, Dementia, Heartburn Medications (Current) Diltiazem XR 240 mg PO once daily Warfarin 2.5 mg PO once daily Lisinopril 40 mg PO once daily Furosemide 20 mg PO once daily Donepezil 10 mg PO once daily Ranitidine 150 mg PO once daily Travoprost Z 0.004% one drop each eye once daily Centrum Silver vitamin PO once daily

1. What pharmacological property of diltiazem differentiate from other CCBs and make it suitable as antiarrhythmic agent? 2. Enlist the signs and symptoms of atrial fibrillation 3. Name any three drugs that can induce arrhythmia.

Key:

1. Diltiazem has actions that fall between the dihydropyridines and verapamil. By acting as a negative inotrope and chronotrope. It have potent coronary vasodilatory effect 2. Rapid heart rate, palpitations, exercise intolerance, and occasionally produce angina, congestive symptoms of shortness of breath or edema. 3. Appetite suppressants Beta blockers Caffeine Cocaine Amphetamines Nicotine in cigarettes Alcohol Some asthma medications Thyroid medications.

HEPATITIS B (CASE # 1) Mrs. QR is a 51-year-old Chinese female referred for further evaluation of her hepatitis B virus (HBV). She is currently being treated for the HBV infection by her primary care physician for the past year. Prior to starting Lamivudine, her HBV DNA quantitative level was 2,422,348 copies/mL and alanine transaminase (ALT) level was 101 IU/L (1.68 kat/L). She brings her laboratory test results in for review, which indicate a detectable HBV DNA level despite being on Epivir. She was born in Hong Kong and immigrated to the United States at the age of 47. She has no complaints of dark urine, pale stools, or yellow eyes or skin. Weight 125 lb (56.8 kg), Height 69 in. (175 cm) Vital Signs: BP: 122/80 mm Hg, P: 80, RR: 20, T 37.1C

1. What signs and symptoms of hepatitis B does the patient have? 2. What is the difference between Hepatitis B vaccine and HBIg? 3. What other pharmacological treatment options are available for Hepatitis?

Key: 1.

a. Easy fatigability, anxiety, anorexia, and malaise. b. Ascites, jaundice, variceal bleeding, and hepatic encephalopathy can manifest with liver decompensation. c. Hepatic encephalopathy is associated with hyperexcitability, impaired mentation, confusion, obtundation, d. and eventually coma. 2. Hepatitis B vaccine, which provides active immunity, and hepatitis B immuneglobulin (HBIg), which provides temporary passive immunity. 3. Interferon 2b (IFN-2b), lamivudine, telbivudine, adefovir, entecavir,and pegylated IFN2a

HEPATITIS C (CASE # 1) The patient is a 51-year-old African American male with chronic hepatitis C virus (HCV) genotype 1A initially presented with new onset jaundice, ascites, cachexia, edema, and encephalopathy. He has been a heavy alcohol user on and off for approximately 20 years, and 2 years ago he started drinking between a pint and a quart of vodka daily. He required hospitalizations 3 times over the course of 3 months for medical management of encephalopathy and ascites, including large-volume paracenteses. Medications (Current) Spironolactone 25mg PO Furosemide 80mg IV prophylactic ciprofloxacin 200mg IV BD lactulose 30ml h.s folic acid Albumin 20 % 100ml IV OD Rifixamine 550mg BD Vitamin K IV BD

Labs: Albumin: 2.8 g/dL, Prothrombin time: 12.9 seconds, International normalized ratio (INR): 1.6 Total bilirubin: 2.2 mg/dL, Platelet count: 65,000 cells/L, AFP: 22 g/L, Ferritin: 214 g/L Creatinine: 1.0 mg/dL 1. What is relation of INR with liver disorder? 2. Name the interferones and there types with doses that are used in the treatment of Hepatitis C? 3. Name the antiviral that are used in the treatment of Hepatitis C? 4. What is the indication of Albumin in this patient? 5. What is the indication of Rifixamine in this patient? 6. What is the indication of Vitamin K in this patient? 7. What is the indication of Lactulose in this patient?

Key: 1. If there is serious liver disease and cirrhosis, the liver may not produce the normal amount of proteins and then the blood is not able to clot normally. Therefore liver disorder INR can result in

increased INR. 2. Peginterferon 2a 180 mcg/wk or Peginterferon 2b 1.5 mcg/wk Peginterferon 2a 180 mcg/wk or Peginterferon 2b 1.5 mcg/wk 3. Boceprevir , Telaprevir , Ribavirin, Entacavir 4. Albumin have established indication for liver cirrhosis and ascites for drainage of ascetic fluid.

5. To reduced intestinal bacterial overgrowth in patient with hepatic encephalopathy 6. For encephalopathy in order to reduce ammonia absorption.