Heart rate

[jeffradd]

67 y.o. man who is presenting for PT after suffering MI weeks ago. His other PMH include: MI - 2 weeks ago, HTN, CHF with EF 25%, afib, osteoporosis, GERD

His meds include: ASA 325 mg QD, Metroprolol XL 100 mg QD, lisinopril 40 mg QD, Imdur 30 mg QD, Lipitor 40 mg QD, NTG SL spray PRN, Furosemide 40 mg QD, Spironolactone 25 mg QD, Digoxin 125 mcg per day, amiodarone 200 mg QD, Ibuprofen 800 mg TID, Percocet 1-2 tabs Q4h PRN pain, Protonix 40 mg per day, Warfarin 5 mg per day

Which are true?

A. Heart rate will not be a good indicator of exercise exertion in this patient

B. Therapy session should be cancelled if Bob's INR is between 2 and 3

C. Bob should take 1 spray of NTG 15 min before each PT session

[Zoggite]

I'm not surprised he's suffering with reflux if he's on 800 mg ibuprofen TID and aspirin 325mg daily! I am also surprised that he hasn't bled to death yet with all that on top of 5mg warfarin a day! And I hope his digoxin levels are being properly monitored as both amiodarone and spironolactone will increase digoxin plasma levels, and he is at greater risk from its cardiac toxicity as he is also on furosemide...
metoprolol + lisinopril: enhanced hypotensive effect;
metoprolol + digoxin: increased risk of AV block and bradycardia;
metoprolol + imdur: enhanced hypotensive effect too...
And the list goes on!
If my Dad was prescribed this cocktail, I would go loopy at whoever prescribed this, as well as at whoever dispensed it without a second thought!

[jeffradd]

so you are saying that both a,b and c are true?

[Jeff]

so you are saying that both a,b and c are true?

I think there's a cultural differrence between the US and the UK.
Your largely private health service funds itself by selling treatment
the publically funded NHS tries to limit costs by limiting treatment.

We are also separated by a common language - you are using drug names with which we are unfamiliar, dose codes that have to be translated (QD would be 4 times a day in the UK) and even the abbreviations have to be translated (is GERD the same as the UK's GORD?)

There are too many unknowns for me to want to answer - and I really can't be bothered to go through the whole translation process to make sure I'm answering properly.

Jeff

[jeffradd]

Gastroesophageal reflux disease=GERD

[jeffradd]

come on jeff help a fellow american out..dont you remember world war 2?

just messing with you, im just a pharm student

[Jeff]

67 y.o. man who is presenting for PT

Physio Therapy?

after suffering MI weeks ago. His other PMH

Personal/Previous Medical History?

include: MI - 2 weeks ago, HTN,

hypertension

CHF with EF 25%

ejection fraction?

afib, osteoporosis,GERD

Gastro Oesophageal Reflux Disease GORD

His meds include: ASA 325 mg QD

aspirin 325mg od

Metroprolol XL 100 mg QD, lisinopril 40 mg QD, Imdur 30 mg QD, Lipitor 40 mg QD, NTG SL spray PRN

GTN spray

Furosemide 40 mg QD, Spironolactone 25 mg QD, Digoxin 125 mcg per day, amiodarone 200 mg QD, Ibuprofen 800 mg TID, Percocet 1-2 tabs Q4h PRN pain

oxycodone+paracetamol

Protonix 40 mg per day

pantoprazole

Warfarin 5 mg per day

Which are true?

A. Heart rate will not be a good indicator of exercise exertion in this patient

B. Therapy session should be cancelled if Bob's INR is between 2 and 3

C. Bob should take 1 spray of NTG 15 min before each PT session

A. Dunno - but maybe I ought to.

B. I thought the target INR was between 2 and 3?
Things that affect our INR [May 2001; 87-5]
which also raises questions about the use of paracetamol prn

C. Probably - depends what PT is though - if Bob is attached to a whole set of wires and you're looking for signs of afib then perhaps not.

Not part of your question but there are concerns about the use of aspirin and ibuprofen at the same time
The FDA said
http://tinyurl.com/3cmoaz
"Health care professionals should consider:
• Counseling patients about the appropriate timing of ibuprofen dosing if they are also taking aspirin for cardioprotective effects.
• With occasional use of ibuprofen, there is likely to be minimal risk from any attenuation of the antiplatelet effect of low dose aspirin, because of the long-lasting effect of aspirin on platelets.
• Patients who use immediate release aspirin (not enteric coated) and take a single dose of ibuprofen 400 mg should dose the ibuprofen at least 30 minutes or longer after aspirin ingestion, or more than 8 hours before aspirin ingestion to avoid attenuation of aspirin’s effect.
• Recommendations about the timing of concomitant use of ibuprofen and enteric-coated low dose aspirin cannot be made based upon available data.
• Other nonselective OTC NSAIDs should be viewed as having the potential to interfere with the antiplatelet effect of low-dose aspirin unless proven otherwise.
• Prescribing analgesics that do not interfere with the antiplatelet effect of low dose aspirin for high risk populations"
The CSM advice is
"The combination of a NSAID and low-dose aspirin can increase the risk of gastro-intestinal side-effects; this combination should be used only if absolutely necessary and the patient should be monitored closely."

Regards

Jeff

[jeffradd]

Jeff thank you very much. i need to read this a few times. wow you put alot of time into this thank you. yes its physio.