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Case No-17

Case No-17. A 53 year old male sent to the emergency room due to difficulty in breathing, easy fatigability and 2-3 pillow orthopnea. He was diagnosed to have arterosclerotic cardiovascular disease.

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Case No-17

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  1. Case No-17 • A 53 year old male sent to the emergency room due to difficulty in breathing, easy fatigability and 2-3 pillow orthopnea. He was diagnosed to have arterosclerotic cardiovascular disease. • The patient is having dysnea or the difficulty to breathe due to impaired gas exchange and pulmonary edema • Easy fatigability is a non specific complaint usually secondary to heart failure due to the reduction of skeletal muscle perfusion. • Orthopnea is dysnea in supine or recumbent position due to increased venous return to the heart in HF. • Arteriosclerosis- hardening of arteries results from deposition of collagen mostly secondary to atheromatous plaque deposition. • All manifestation indicate a probable left sided heart failure.

  2. Immediate Management • Oxygen therapy to relieve dysnea, improves tissue oxygenation etc. • Use of a tiltable bed to prevent orthopnea, and advocate rest. • Anti anxiety drugs like diazepam, to relieve anxiety.

  3. Pharmacological Management of the Case • Control of excess fluid –this can be achieved by giving diuretics; the choice of the agent depends on the systemic conditions and other factors. • Thiazide Diuretics – they prevent re-absorption of NA and Cl .Chlorothiazide in the dose of 25-50 per day could be a good choice • Loop Diuretics-they reversibly inhibit NA, K and Cl absorption. This group of drugs like furesimide could also be used in refractory HF as IV. • Potassium Sparing Diuretics –these drugs could be administered alone or in combination with others. Low dose of spiranololactone at 25mg/day is effective

  4. Inotropes • The improvement of myocardial contractility by means of cardiac glycosides is useful in the control of HF. • By invoking increased intracellular Ca they increase positive inotropic effect. • Digitalis , Digoxin can be given to increase the rate of contraction and thereby cardiac output.

  5. Sympathomimetic Amines • Dopamine in the range of 2 to 10 ug/kg per min. • Dobutamine continuous infusions of 2.5 to 10 ug/kg per min Anti-Hypertensives • ACE inhibitors reduce the impedance to left ventricular ejection • The use of beta blockers is controversial other safer agents are advocated.

  6. Anticoagulants & Antiarrythmics • Patients with severe HF are at increased risk of pulmonary emboli secondary to venous thrombosis, low dose warfarin is recommended. • Sudden death, due to ventricular fibrillation is common in HF. Amiodarone, a class III antiarrhythmic is well tolerated. Prognosis • Prognosis of HF is poor in cases with ejection fraction below 15% which is refractory to pharmacological interventions and surgical revascularisation.

  7. Thank You ! “Pharmacology is the backbone of Medicine”

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