What additional history would you obtain from this patient?
In the case under discussion, the patient has no significant cardiac, hypertension, and dyslipidemia history. After the placement of a drug-eluting stent (DES), slight lipid elevation and high blood pressure are observed. Therefore, it is required to pay attention to additional history to be obtained from the patient. If no clear information is given in his medical history, communication with the man should give certain results.
First, it is necessary to clarify if chest pain has ever bothered the man. The focus on such conditions as fatigue, the lack of unreasonable loss of energy, and depression plays an important role as well. Regarding the fact that the patient is obese and hypertensive, it is reasonable to ask if there is a diabetes history in his family (Baumann et al., 2016). However, hypertension (systolic is about 136 and higher, and diastolic is about 81 and higher) after stent placement is a normal thing according to Khoury et al. (2018). Therefore, it is recommended to obtain some general facts about the patient, including his dietary habits, attitudes to physical activities, allegories, and past surgeries or treatment plans if any were offered.
What choice of drugs, dose would you include in your plan of care? And for how long?
Control of hypertension is an important step in this care plan. For example, b-blockers and ACE-Is should be included (“Clinical practice guidelines,” 2014). These drugs can also reduce the size of a potential infarct in the future. For example, the patient should take metoprolol 25 mg daily as the initiation dose and 100 mg as the target dose (“Clinical practice guidelines,” 2014). This drug should be taken seven days after discharge with the required follow-up to identify the changes.
Weight control is also required. B-glucan 3 g per day during 3-6 months will help to decrease the level of lipoprotein cholesterol (“Clinical practice guidelines,” 2014). The rationale for taking this drug is to avoid complications connected with obesity and high cholesterol levels. Finally, antiplatelet therapy will prevent stent thrombosis (Ghoorah, Campbell, Kent, Maznyczka, & Kunadian, 2016). Clopidogrel 75 mg daily should be given for one month for post-STEMI patients (“Clinical practice guidelines,” 2014). However, the first dose has to be 300 mg. If no negative reaction is observed, the therapy should be continued. If this drug was given before, its effects have to be evaluated, and some changes may be offered, including the possibility to combine clopidogrel with aspirin.
Give the rationale for your drug choice. In general, the therapy for post-STEMI patients is based on several types of drugs being taken at the same time. First, hypertension control cannot be ignored. The fact that the patient is obese also determines care. Finally, the condition of the blood should be regulated. The rationale for these drugs’ choice remains clear. The patient has to control his physical condition and avoid serious complications after the placement of the DES. There is a thought that lean patients are exposed to a greater risk of complications in comparison to obese patients (Numasawa et al., 2015). However, obesity is also a cause of multiple cardiovascular complications. Therefore, it is necessary not to allow new problems and changes being developed after the stent placement.
Each chosen drug is an opportunity for the patient to control the different conditions of his health. Obesity is his regular problem during a certain period. In its turn, hypertension and elevated liquids can be the result of the DES surgery. It is rational to use medications to stabilize the condition of the patient and make sure that blood clots and thrombosis will not bother the patient after his discharge.
How will you evaluate the effectiveness of the treatment and when would you evaluate it?
The evaluation of the effectiveness of the offered treatment plays a crucial role in this care plan. It is not enough to check the results of the signed drugs. It is also important to assess the general physical condition of the patient, the blood, and mental health changes (if any). As a rule, patients return to their routines in a few days after surgery. Follow-ups by a cardiologist and a primary care physician are required. As a rule, one week is the established period for regular visits. The effects of the drugs have to be observed and reported. Then, it is possible to decrease the frequency to every 3-6 months during the first year. The methods of evaluation may vary. However, in the majority of cases, a physical examination and a clinical history have to be taken into consideration. Stress tests after the placement of the stent are recommended at least two times per six months (“Clinical practice guidelines,” 2014). In a week, a general analysis of the blood should be developed to check for inflammation or other possible threats.
What risk factors would guide your choice?
In the case under analysis, risk factors are connected not only with the stent placement. The patient also suffers from obesity and recently developed hypertension. Therefore, such risk factors as bleeding or blood vessel damage guide my choice of clopidogrel and aspirin. These drugs help to prevent blood clots and associated complications. It is necessary to admit that the patient uses a drug-eluting stent, meaning that a special substance can stop excess bleeding in case of an emergency. Infection and kidney damage are possible and have to be controlled during the first week of treatment (Khoury et al., 2018). As a result, a follow-up with a primary care physician is recommended. Arrhythmia can bother the obese patient after the stent placement. Irregular heartbeats can be a sign of different cardiovascular, respiratory, and neurological complications. Finally, the combination of such factors as hypertension, cardiovascular problems, and obesity may promote a pre-diabetic condition. The level of glucose in the blood is another factor for consideration in this treatment plan.
Provide pharmacological and non-pharmacological education for this patient. Despite the offered medications and assessments, the patient should have the guarantees that all therapies, both pharmacologic and non-pharmacologic, are safe and effective. Therefore, patient education after the placement of a stem cannot be ignored. From a pharmacological point of view, the patient must receive an explanation about harmful decisions that should be avoided. First, it is necessary to follow the prescriptions given by a therapist or a leading cardiologist and take all the drugs according to the established schedules. Independently chosen medications can cause unpredictable changes. For example, nitrates and diuretics after the stent placement and hypertension should be avoided because of the reduction of preload (“Clinical practice guidelines,” 2014). Glucocorticoids are also not recommended during the first four weeks after surgery because of the possible arterial embolism (“Clinical practice guidelines,” 2014). Additional consultation with a doctor may improve pharmacologic education. Non-pharmacologic strategies in patient education include the control of weight, the level of glucose and cholesterol in the blood, and the choice of a healthy diet. Lifestyle changes and stress avoidance may help the patient to reduce the possibility of STEMI complications.
References
Baumann, S., Koepp, J., Becher, T., Huseynov, A., Bosch, K., Behnes, M.,… Akin, I. (2016). Biomarker evaluation as a potential cause of gender differences in obesity paradox among patients with STEMI. Cardiovascular Revascularization Medicine, 17(2), 88-94.
Clinical practice guidelines: Management of acute ST segment elevation myocardial infarction (STEMI). (2014). Web.
Ghoorah, K., Campbell, P., Kent, A., Maznyczka, A., & Kunadian, V. (2016). Obesity and cardiovascular outcomes: a review. European Heart Journal: Acute Cardiovascular Care, 5(1), 77-85.
Khoury, S., Steinvil, A., Gal-Oz, A., Margolis, G., Hochstatd, A., Topilsky, Y.,… & Shacham, Y. (2018). Association between central venous pressure as assessed by echocardiography, left ventricular function and acute cardio-renal syndrome in patients with ST segment elevation myocardial infarction. Clinical Research in Cardiology, 1-8. Web.
Numasawa, Y., Kohsaka, S., Miyata, H., Kawamura, A., Noma, S., Suzuki, M.,… & Fukuda, K. (2015). Impact of body mass index on in-hospital complications in patients undergoing percutaneous coronary intervention in a Japanese real-world multicenter registry. PLoS One, 10(4), 1-17. Web.