Discuss the appropriate next step for pharmacologic management of D.S’. dyslipidemia, along with pharmacologic agents for her comorbidities.

• Please briefly justify/explain your choice/s of pharmacologic agent/s (Please include the complete regimen).

According to the American Heart Association, patients between the age of 40-75 with diabetes and an LDL-C level of ≥70 mg/dL should be on moderate-intensity statins without calculating 10-year ASCVD risk. Additionally, diabetes mellitus patient between the age of 50-75 are at higher risk, so the American Heart Association suggest using “high-intensity statin to reduce the LDL-C level by ≥50%”. Based on the American Heart Association recommendation, our patient, D.S., should be on high-intensity statins because she has diabetes and fit into the high-risk age category.

Also, I calculated the 10-year risk of ASCVD using platforms such as the 2018 Prevention Guidelines Tool CV Risk Calculator and American College of Cardiology ASCVD risk Estimator Plus. Both tools calculated our patient’s current 10-year ASCVD risk to be 8.9% which is an intermediate risk so the patient should be started on statin therapy.  I would follow the American Heart Association recommendation and start Ms. D.S. on high-intensity statin therapy of either Atorvastatin (40 mg) or rosuvastatin (20 mg). However, if the patient develops statin intolerance then I would move the patient to moderate intensity Atorvastatin (10-20 mg) or rosuvastatin (5-10mg). Before starting the statin therapy, I would check the lipids, A1c, CK and LFTs for baseline. If the patient develops any muscle pain, hepatitis or myositis symptoms then I would stop the statin therapy and once the patient recovers, I will start off with a lower dose such as moderate-intensity instead of higher intensity statins.

 

 

Complete drug regimen for the patient:

1. Atorvastatin 40 mg
2. Continue Lifestyle modification: Metoprolol succinate 25 mg Once Daily
   1. intake of vegetables, fruits, legumes, nuts, whole grains and fish are recommended. A diet containing reduced amounts of cholesterol and sodium can be beneficial
   2. Be routinely counseled to optimize a physically active lifestyle
3. Metoprolol Succinate 25 mg orally per day
4. Lisinopril
5. Furosemide

 

Discuss the pharmacologic management of A. Fib, along with pharmacologic agents for her comorbidities.

• Please briefly justify/explain your choice of pharmacologic agent/s (Please include the complete regimen).

 

Based on the patient history of rales and 2+ pitting edema, it is suggesting congested Heart failure, which should be addressed first before treating the A-fib. In order to manage the CHF, the patient should be placed on Lasix (Furosemide), Oxygen and position the patient in upright. Since the patient is stable and the a-fib started more than 48 hours ago, I would start with a rate/rhythm control such as: IV digoxin or amiodarone followed by anticoagulation. Based clinical trials, AF patient treating with amiodarone experienced both higher treatment success and a more rapid response compared to those who received IV digoxin. Therefore, I would go with IV amiodarone as treatment choice for this patient to stabilize the into sinus rhythm.

This patient needs to be on anticoagulation as the CHA2DS2-VASc score for this patient is 4.

I would suggest the patient to be on Warfarin because  it is much cheaper and can be easily reversed compare to NOAC.  For this patient who frequently gets lab drawn considering all the comorbidities should be easy to monitor the INR between 2-3. Also, the patient has an LVEF 28% which means the patient could have AICD placement because all patients with ejection fraction less than 35% and not on category 4 should be placed on AICD to prevent sudden cardiac death. If the patient also has the cardiac implantable device then the NOAC therapy efficacy data is limited so it would be better off to go with well studies drugs such as Warfarin. I do not think this patient is a good candidate for cardioversion because she has structural heart disease and other co-morbidities.

The patient should be on Warfarin for long term for anticoagulation and oral maintenance dose of amiodarone 400 mg orally to sustain the sinus rhythm.

Complete Discharge drug regimen for the patient:

1. Atorvastatin 40 mg
2. Warfarin 5 mg orally once a day
3. Amiodarone 400 mg orally per day
4. Continue Lifestyle modification: Metoprolol succinate 25 mg Once Daily
   1. intake of vegetables, fruits, legumes, nuts, whole grains, and fish is recommended. A diet containing reduced amounts of cholesterol and sodium can be beneficial
   2. Be routinely counseled to optimize a physically active lifestyle
5. Metoprolol Succinate 25mg orally per day
6. Lisinopril
7. Furosemide

Sources:

1. https://www.heart.org/-/media/files/health-topics/cholesterol/chlstrmngmntgd_181110.pdf
2. http://static.heart.org/riskcalc/app/index.html#!/baseline-risk
3. http://tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/advice/riskgraph/
4. Shojaee, M., Feizi, B., Miri, R., Etemadi, J., & Feizi, A. H. (2017). Intravenous Amiodarone versus Digoxin in Atrial Fibrillation Rate Control; a Clinical Trial. Emergency (Tehran, Iran), 5(1), e29.
5. https://www.drugs.com/amiodarone.html
6. https://www.drugs.com/dosage/warfarin.html
7. https://clincalc.com/Cardiology/Stroke/CHADSVASC.aspx
8. https://www-uptodate-com.york.ezproxy.cuny.edu/contents/overview-of-atrial-fibrillation?search=atrial%20fibrillation&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H440860093
9. https://onlinemeded.org/spa/cardiology/acls-rhythms/acquire