Discussion Question 1: For These Questions, Please Read The ✓ Solved

Discussion Question 1for This Questions Please Read The Following Cas

Read the case study of Mr. EBR, a 74-year-old retired Hispanic man with coronary artery disease (CAD) presenting with substernal chest pain over the past three months. The pain is exertional, relieved by rest or nitroglycerin, and similar but less severe than his previous MI. He has no recent symptoms of shortness of breath, palpitations, or other systemic issues. His medical history includes well-controlled diabetes, hypertension, hyperlipidemia, stage 3 chronic kidney disease (CKD), and diabetic neuropathy. His medications include atenolol, lisinopril, aspirin, simvastatin, and metformin. Physical examination is mostly unremarkable, with normal vital signs, clear lungs, no JVD or carotid bruits, and normal cardiac exam. His extremities show no edema or cyanosis, with normal pedal pulses.

Questions to consider include what to add to his current treatment plan, whether any medications should be discontinued, how CKD influences treatment choices, the rationale for multiple antihypertensives, and the benefits of aspirin therapy in this context.

Sample Paper For Above instruction

Introduction

This case study involves a comprehensive assessment of a patient with stable angina, underlying comorbidities, and pharmacologic management considerations, especially in the context of stage 3 CKD. Proper management requires adjusting therapies to optimize cardiovascular health while considering renal function, medication interactions, and overall risk reduction.

Updated Treatment Plan

Given Mr. EBR's presentation with exertional angina, the primary goal is to optimize anti-anginal therapy and address residual cardiovascular risks. The current medications include beta-blocker (atenolol), ACE inhibitor (lisinopril), aspirin, statin, and metformin. To improve symptom control and prevent progression, adding a long-acting nitrates or calcium channel blocker such as amlodipine could be considered, especially if anginal episodes persist. Additionally, since his angina appears stable but persists, the addition of a Ranolazine might be beneficial due to its efficacy in chronic angina management and renal safety profile.

Medications Discontinuation and Adjustments

In patients with CKD, medication choices often need adjustment. For example, high-intensity statins like simvastatin 80 mg should be reviewed for safety, as high doses increase the risk of myopathy, especially in CKD. It is advisable to consider lowering the dose or switching to a statin with a better safety profile in CKD such as pravastatin or atorvastatin at appropriate doses. Lisinopril, an ACE inhibitor, should be continued as it provides renal and cardiovascular benefits, though renal function and potassium levels need close monitoring due to CKD. There is no indication to discontinue atenolol unless adverse effects emerge, but caution is warranted with beta-blockers in CKD, especially if bradycardia occurs.

Impact of Stage 3 CKD on Treatment Choices

Chronic kidney disease stage 3 (moderate CKD) affects pharmacotherapy choices because of altered drug metabolism and increased risk of adverse effects. For example, dosing of certain antihypertensives and statins needs to be adjusted to prevent toxicity. Moreover, CKD influences the choice of drugs that may have nephrotoxic potential or require renal function monitoring, such as ACE inhibitors, which can both preserve renal function and cause hyperkalemia or acute kidney injury if not carefully managed.

Rationale for Multiple Antihypertensives

Using more than one antihypertensive class aims to achieve more effective blood pressure control, reducing cardiovascular risk. Hypertension in CKD often necessitates combination therapy because a single agent may not sufficiently control BP while minimizing side effects. For Mr. EBR, ACE inhibitors, along with beta-blockers or calcium channel blockers, can synergistically reduce blood pressure, prevent left ventricular hypertrophy, and slow CKD progression.

Role of Aspirin Therapy

Aspirin’s antiplatelet effect decreases the risk of thrombotic events like MI and stroke, which is crucial in patients with established CAD. It also provides secondary prevention benefits by reducing the progression of atherosclerotic plaques. While aspirin increases bleeding risk—especially in CKD—its benefits in secondary prevention generally outweigh the risks for patients with significant coronary artery disease, provided bleeding risk is carefully monitored.

Conclusion

In conclusion, managing Mr. EBR’s chronic stable angina in the setting of CKD involves tailored pharmacologic strategies that balance efficacy with safety. Adjusting current medication doses, considering adding anti-anginal medications, ensuring ongoing monitoring of renal function, and reinforcing the importance of secondary prevention are key components of his comprehensive care plan.

References

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• Chapman, A. B., et al. (2022). Management of Patients With Chronic Kidney Disease and Cardiovascular Disease. JAMA, 327(8), 785–794.
• Herrington, W., et al. (2020). Cardiovascular Risk and CKD: Management Strategies. Current Cardiology Reports, 22(4), 27.
• Levey, A. S., et al. (2021). KDIGO 2021 Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease. Kidney International, 99(3), 475–500.
• McDonald, C., et al. (2018). Pharmacological Treatment of Stable Angina. The Lancet, 392(10187), 729–738.
• Mozaffarian, D., et al. (2019). Heart Disease and Stroke Statistics—2019 Update. Circulation, 139(10), e56–e528.
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• Woolf, S. H., et al. (2020). Effective Strategies to Improve Cardiovascular Disease Prevention in CKD Patients. Kidney International Supplements, 10(1), 66–71.
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• Zoccali, C., et al. (2018). Dialysis and Cardiovascular Disease: Pathophysiology and Management. Nephrology Dialysis Transplantation, 33(4), 652–661.