Access the most clinically current information surrounding the practice of personalized, customized medicine—and its application to the most complex and challenging cardiometabolic patient cases.
Management of Heart Failure with Preserved Ejection Fraction
A 73-year-old female with a medical history of paroxysmal atrial fibrillation and hypertension visits for an annual exam. She is presented with dyspnea on exertion that has been progressive for the last 18 months and have been hospitalized for pneumonia three months ago. Her dyspnea has been worse since her last hospitalization. She also has two pillow orthopnea and occasional PND.
MEDICAL HISTORY
- Paroxysmal atrial fibrillation
- Hypertension
PHYSICAL EXAMINATION:
- Height: 5'2''
- Weight: 90kg
- BMI: 36.2 kg/m2
- BP: 154/79 mmHg - regular 18 - RR
- HR: 94
- Afebrile
- JVP - difficult but appears to be 3 cm above clavicle sitting
- Chest - clear to P & A
- Cor - regular rhythm S4
- Abd - normal
- Ext - 1+ edema
MEDICATIONS:
- Lisinopril 5mg qd
- Chlorthalidone 25 mg qd
- Apixaban 5 mg bid
LAB RESULTS:
- Sodium - 138 mmol/L;
- Potassium - 4.3 mmol/L;
- Bicarbonate - 24 mmol/L
- BUN - 33 mg/dL;
- Creatinine - 1.4 mg/dl
- eGFR - 39ml/min/1.73/m2
- Hemoglobin - 11.9 g/dL
- HbA1c - 5.8%
- NT pro BNP - 297 pg/mL (age-specific and sex-specific normal range, 10 to 218 pg per milliliter)
- Fasting lipids:
- Cholesterol total = 210 mg/dL,
- HDL = 54 mg/dL,
- LDL = 150 mg/dL,
- TGs = 120 mg/dL
- ECG normal sinus rhythm, otherwise unremarkable
ECHO IN HOSPITAL DEMONSTRATED
- LVEF 50% Pulmonary artery systolic pressure = 45 mm Hg
- Evidence of moderate diastolic dysfunction
- Normal left ventricular wall thickness
- Moderately enlarged left atrium
- Mild aortic sclerosis with no stenosis
- Mild to moderate tricuspid regurgitation with mildly reduced right ventricular function
Question: What would you do next?
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Expert Commentary on the Case Conclusion
Mastering the Prior Authorization Process to Meet Patient Needs
A 61-year old African-American male with a history of ASCVD, hypertension and myocardial infarction visits for an annual exam. Physician is considering a PCSK9 inhibitor option as this patient needs further LDL-C lowering medication options. This patients has been referred to a pharmacist in the lipid clinic to fill out prior authorization paperwork.
MEDICAL HISTORY:
- ST-segment elevation myocardial infarction – 12/1/16
- Hypertension
- Ischemic cardiomyopathy
- LVEF 20-24% s/p implantation of automatic cardioverter/defibrillator
- Statin intolerance
MEDICATIONS:
- Aspirin 81 mg P.O daily
- Lisinopril 2.5 mg P.O daily
- Metoprolol 25 mg P.O daily
- Spironolactone 12.5 mg P.O daily
- Ezetimibe 10 mg P.O daily
LABORATORY RESULTS:
- Current LDL-C = 145 mg/dL
Question: What should the pharmacist do next?
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Expert Commentary on the Case Conclusion
A Case of Resistant Hypertension
A 67 year-old male with a history of hypertension, CAD (s/p PCI with stenting of RCA), hyperlipidemia, GERD, BPH, and DKD visits for an annual exam. He reports measuring home BP infrequently, but reports it is usually around 140-150/70-80 mmHg. At his visit, the following are measured:
PHYSICAL EXAM:
- BMI: 33 kg/m2
- BP: 188/94 mm Hg
- HR: 72 bpm
- Cardiac exam: regular rhythm,
normal S1S2
- Lungs: clear; peripheral pulses
symmetrical
- Absent carotid or abdominal
bruits
LABORATORY RESULTS:
- eGFR: >60 ml/min/1.73 m2
- Serum K+: 3.6 mEq/L
- HbA1c: 6.1%
- Serum Na+: 142 mEq/L
MEDICATIONS:
- Losartan HCT: 100/25 mg qday
- Carvedilol: 12.5 mg bid
- Amlodipine: 5mg qday
- Clonidine: 0.1 mg qhs
- Atorvastatin: 10 mg qday
- ASA: 81 mg qday
After ordering an aldosterone-to-renin ratio (ARR) and 24-hour urine test for aldosterone, cortisol, sodium, and protein, it is decided to stop losartan hct and substitute it with lisinopril 40 mg qday and chlorthalidone 25 mg qam. Clonidine is also stopped and amlodipine is increased to 10 mg qday. At the patient’s 1 month follow up, his office BP (automated, 5-serial readings, unattended) is 165/92 mmHg. And the following is found during his exam:
LABORATORY RESULTS:
- Aldosterone/PRA: 11 ng/dL 0.6
ng/ml/hr
- 24-hr urinary aldosterone: 14 mcg
- 24-hr urinary sodium: 218 meq
Patient Case Question: Which medication change should be recommended?
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Expert Commentary on the Case Conclusion
Balancing Glucose Control and Weight Gain
A 52 year old woman who was diagnosed with T2DM in 2001 is seen in consultation to improve glucose control. She has no hypoglycemic symptoms and her finger stick glucoses are 132-187 mg/dl AC and 156-398 mg/dl hs. She is frustrated by weight gain (17 lbs in past 11 months) and acknowledges stress eating due to financial concerns. She mentions that she is “too busy” to exercise and per her husband she snores and wakes up tired. She has previously declined a sleep study since she is “sure she doesn’t have sleep apnea.” Upon examination the following is documented:
MEDICAL HISTORY:
- Background diabetic retinopathy
- Diabetic polyneuropathy
- Diabetic nephropathy with microalbuminuria
- Obesity
- Hypertension
- Dyslipidemia
- Depression
FAMILY HISTORY:
- T2DM in mother and 3/5 siblings
SOCIAL HISTORY:
- She and husband own struggling business
- No tobacco, alcohol or illicit drug use
PHYSICAL EXAM:
- Tearful when discussing problems
- Generally and truncally obese
- Does not appear acromegalic or cushingoid
- BP: 128/82 mmHg
- HR: 78 bpm
- BMI: 43.4 kg/m2
- Feet: loss distal cold sensation; normal vibration and monofilament sensation
LABORATORY RESULTS:
- HbA1c: 9.7%
- Creatinine: 0.8 mg/dl
- GFR>60 mL/m/1.73m2
- K+: 4.5mM
CURRENT MEDICATIONS
- Lispro insulin 80 unit base dose with sliding scale AC
- Basaglar insulin 135 units bid
- Lisinopril 40 mg qd
- Atorvastatin 40 mg qd
- Sertraline 100 mg qd
PRIOR MEDICATIONS
- Metformin (GI upset)
- Liraglutide (dizziness)
- Empagliflozin (3 time/night urination)
- Pioglitazone (prior refusal due to concerns about bone fractures and weight gain)
Patient Case Question: How do you improve glucose control in this patient?
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Expert Commentary on the Case Conclusion
Severe Hypertriglyceridemia
A 45 year old man with known CHD S/P multiple PCIs/stents, T2DM since 1994, and hypertension for >20 years is hospitalized 5 months previously for chest pain. During his admission, the following is found:
LABORATORY RESULTS:
- TG: 2509 mg/dl
- HbA1c: 10.2%
MEDICATIONS:
- Gemfibrozil 600 mg BID
- DHA + EPA 2.5 g
- Atorvastatin 20 mg
- Glipizide 10 mg
- Metformin 850 mg BID
The patient was discharged on same medications plus a low fat diet and insulin glargine 10 units daily. His home glucose monitoring recordings have been in the 100-150 mg/dL range during several months of increasing insulin dosage. At his next clinic visit:
MEDICATIONS:
- Glargine 72 units daily
- Metformin 1 g BID
- Glipizide 10 mg BID
- Rosuvastatin 20 mg
- Gemfibrozil 600 mg BID
- Fish oils 1.6 g BID
- Clopidogrel 75 mg
- Aspirin 81 mg
PHYSICAL EXAM:
- Weight: maximum 280 lbs; patient had lost 14lbs since his hospitalization on a low fat diet
- BP: 140/68 mmHg
- BMI: 34.7 kg/m2
- Eruptive xanthomata on back and arms
LABORATORY RESULTS:
- TC: 259 mg/dL
- TG: 1965 mg/dL
- HDL-C: 35 mg/dL
- HbA1c: 7.8%
- AST, ALT: normal
- Creatinine: 1.0 mg/dL
- TSH: 1.6 mIU/L
- U/A albumin: – 789 mg/g
SOCIAL HISTORY:
- Eats fish approximately 1-2 times
per month, whole grains
approximately 1 serving a day,
fruits and vegetables 4-5 servings
a day; occasionally he eats out,
but when he does, he eats salads
- No EtOH
- No tobacco
- Walks approximately 30 minutes
daily, but this is difficult due to
symptoms of peripheral neuropathy
Patient Case Question: What is the next best step in the management of this patient to reduce his triglyceride level?
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Expert Commentary on the Case Conclusion
Challenges with High LDL-C Levels
A 50 year old woman who is a busy mom working and going to school part time is referred for treatment of high cholesterol. Her weight has never been a problem but can vary by approximately 5 pounds; however, her weight is currently higher than her “goal weight.” The patient tries to eat healthy, but is not sure what diet changes to make. She likes desserts and has switched to portioned ice cream bars but eats 2 per day. The patient also does not enjoy exercise, but will occasionally walk on a treadmill. Her exam reveals:
MEDICAL HISTORY:
- High cholesterol over the last “few” years
- Depression and anxiety
- Not menopausal
FAMILY HISTORY:
- Mother has elevated cholesterol levels
PHYSICAL EXAM:
- BMI: 24.5 kg/m2
- Waist circumference: 83 cm
- BP: 132/85 mmHg
LABORATORY RESULTS:
- Cholesterol: 321 mg/dL
- TG: 115 mg/dL
- HDL-C: 73 mg/dL
- LDL-C: 223 mg/dL
MEDICATIONS:
- Alprazolam- 0.75 mg daily
Patient Case Question: How would you manage this patient?
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Expert Commentary on the Case Conclusion
Developments in Type 2 Diabetes treatment to decrease the risk of hypoglycemia
A 53-year old male with a past history of diabetes for 7 years is referred to you by his cardiologist. He was 100 pounds heavier at the diagnosis and this weight loss is unintentional. At his visit, the following are measured:
Medical history:
- Severe hypertriglyceridemia
- Hypertension
- CKD (eGFR 49 ml/min)
- 3-vessel CHD
- S/P PCI,
- LVEF – 43%
- Claudication
- Hyperkalemia
- increased LFTs
- macular edema
- proliferative retinopathy
Social and Family history:
- Minimal alcohol
- S/P tobacco- 8 packs-years,
- Works as roofer
- Father- T2DM, CHD
Review of symptoms:
- Dyspnea on exertion
- Erectile dysfunction
- Peripheral sensory neuropathy
Physical Exam:
- Pulse -70
- BP 160/88
- Weight 89 kg
- BMI 26.6 kg /m2
- Thyroid – upper limit of normal (ULN)
- Gr 2/6 SEM LLSB and apex
- Reduced pedal pulses
- 2+ lower extremity edema
- Charcot left foot
Labs:
- HbA1c – 10.5%
- BUN – 32 mg/dL
- Creatinine – 1.27 mg/dL
- eGFR – 59 mL/min
- Potassium – 4.1 mmol/L
- Cholesterol – 166 mg/dL
- Triglycerides – 209 mg/dL
- HDL-C – 31 mg/dL
- LDL-C – 93 mg/dL
- Non-HDL-C – 135 mg/dL
- ALT – 42 U/L, AST 25 U/L
Current Medications:
- Metformin 1000 mg BID
- Acetylsalicylic acid (ASA) 81 mg
- Lisinopril
- Spironolactone 25 BID
- Nitroglycerin (NTG) 0.4 SL PRN
Additional information about patient:
- Patient is fearful of hypoglycemia, as he has seen his father be hospitalized for this condition multiple times
- Based on patient’s medical profile and HbA1c of 10.5%, treatment intensification may be necessary; however, he is hesitant to intensify his treatment
Based on your patient’s profile, laboratory results, and discussion with him, what will be your next step in treating this patient?
Select an answer to view the case conclusion
Expert Commentary on the Case Conclusion
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