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NSTEMI not STEMI

Medical management dont bother about medical intervention, surgery etc.
1. List the criteria included in the definition of sepsis.
a. Sepsis is defined as the presence (probable or documented) of infection
together with systemic manifestations of infection
b. Severe sepsis is defined as sepsis plus sepsis-induced organ dysfunction or
tissue hypoperfusion
2. List the risk factors for developing a healthcare-associated pneumonia (HCAP).
a. Nursing home or long term care facility
b. Hospitalization for at least 2 days within past 90 days
c. Hemodialysis
d. Recent (30 days) antibiotic use, wound care, chemotherapy, infusion therapy at
home or at healthcare facility
e. Contact with family member with infection caused by MDR pathogen
3. Recommend appropriate antibiotic therapy for the treatment of HCAP.
a. If MRSA suspected
i. IV Linezolid 600mg q12h
ii. IV Vancomycin 15-20mg/kg q8-12h
b. MSSA
i. IV Oxacillin 2g q4h
c. Empiric without risk factors of MDR
i. IV Ceftriaxone 2g q24h
ii. IV Ampi-Sulbactam 3g q6h
iii. IV Ertapenem 1g q24h
iv. IV Levofloxacin 750mg q24h
d. Empiric with risk factors of MDR
i. Antipseudomonal cephalosporin
i. IV Cefepime 2g q24h
ii. IV Ceftazidime 2g q8h
ii. Antipseudomonal carbapenem
i. Imipenem 0.5-1g q6h
ii. Meropenem 1g q8h
4. State the signs, symptoms and lab tests that can be used to make a diagnosis of
non-ST elevation myocardial infarction (NSTEMI).
a. pressure-type chest pain that typically occurs at rest or with minimal exertion
lasting 10 minutes
b. starts retrosternal area and can radiate to either or both arms, the neck, or the
jaw
c. diaphoresis, dyspnea, nausea, abdominal pain, or syncope
d. Less commonly: nausea and vomiting, diaphoresis, unexplained fatigue, and
syncope
e. Atypical symptoms: epigastric pain, indigestion, stabbing or pleuritic pain,
increasing dyspnea in the absence of chest pain
f. ECG: ST depression, transient ST-elevation, or new T-wave inversion
g. Rise in cardiac troponins (biomarker for myocardial necrosis without =
unstable angina)
5. List the risk factors for a patient having a myocardial infarction.
a. older age
b. male sex
c. positive family history of CAD
d. presence of peripheral arterial disease
e. diabetes mellitus
f. renal insufficiency

g. prior MI
h. prior coronary revascularization
6. Recommend appropriate medical treatment for a patient presenting with a NSTEMI.
a. SL nitroglycerin 0.3-0.4mg q5min x3 doses IV if persistent (0.6-1.2mg/h)
i. Symptomatic relief of chest pain
ii. If not having pains now dont need to give maybe just order prn
b. PO Aspirin 100mg OD
i. Clopidogrel
i. Loading 300mg maintenance 75mg OD for 3-12 months
ii. Ticagrelor
i. Loading 180mg maintenance 90mg BD for up to 12 months
c. PO beta blockers within 24h
i. Except if patient has heart failure, low-output state, risk of cardiogenic shock
or if beta blockade contraindicated
ii. For hypertension and tachycardia
iii. Prefer cardioselective agents:
i. Metoprolol 25-50mg BD
ii. Atenolol 50-100mg OD
d. Anti-thrombotic/anti-coagulant therapy
i. To prevent further thrombosis at site of injury
ii. SC enoxaparin 1mg/kg q12h (if CrCl <30 q24h)
iii. UFH Loading 60IU/kg (max 4000IU), maintenance 12IU/kg/h (max 1000IU/h)
iv. Or SC fondaparinux 2.5mg OD
v. For duration of hospitalization or until percutaneous coronary intervention is
done
i. In practice 3-5days
e. High intensity statin shown to be more beneficial for NSTEMI
i. Atorvastatin or Rosuvastatin
ii. Atorvastatin 40mg ON
f. ACEI or ARB
i. Beneficial for morbidity and mortality but not necessarily immediately post-MI
g. Note: specifically for this case sepsis, hypotension, preferably stop beta
blocker and ACEI to prevent lowering the bp further
7. Recommend appropriate monitoring parameters for efficacy and toxicity of the
drug therapy for a patient with HCAP or NSTEMI.
a. Vitals (T, RR), CRP, WBC back to baseline efficacy (HCAP)
b. Allergic reaction, diarrhea, renal function (more because pt already has CKD,
not because drug is nephrotoxic) toxicity (HCAP)
c. No recurrence of chest discomfort, reduced SOB efficacy
d. Symptoms of bleeding (anticoagulant),
e. Vomiting blood, heartburn, gastric bleeding, black tarry stools (Aspirin)
f. BP, Creatinine, K (ACEI)
g. BP, HR (beta blocker)
1. Does RMN meet the criteria for a diagnosis of sepsis? What is the difference
between SIRS and sepsis?
a. SIRS: T >38 or <36; HR > 90; RR > 20; WBC > 12 or < 4 (2 or more)
b. Sepsis: systemic response to infection = presence of documented/suspected
infection + SIRS
c. T: 39.2
d. Elevated WBC
e. Raised CRP
f. Suspected infection
g. Therefore meets criteria for diagnosis of sepsis

2.

3.

4.

5.

6.
7.

h. SIRS can be caused by other reasons other than infection

What risk factors does RMN have to classify his pneumonia as HCAP?
a. Nursing home or long term care facility
b. Hospitalization for at least 2 days within past 90 days (4 days, 2 months ago)
c. Cannot be treated like community-acquired: may have some contact with the
healthcare system
d. Controversy: certain risk factors may cause false classification and cause over
treatment with very broad spectrum antibiotics
What would you recommend as initial, empiric antibiotic therapy for RMNs HCAP?
Drug regimen must include drug, dose, frequency and route of administration.
a. CrCl = 140-85 x 67 / 72 x 175 = 25.85 (ADJUST!)
b. 1st line: Piperacillin tazobactam 3.375g q6h or 4.5g q8h (because come in 4.5g
vials more convenient)
c. Cefepime 2g q8h (ceftazidime local resistance quite high, not used as 1st line
anymore)
d. Imipenem Meropenem (try not to use as 1st line)
e. Duration: 5-7 days but stopping depends on response. If respond quickly, stop
at 5. Stop later if respond slower
i. Can de-escalate and oralise if respond
ii. Response: becoming afebrile
What signs, symptoms and lab tests are consistent with the diagnosis of a NSTEMI?
a. Chest discomfort, difficulty breathing (symptom)
b. No signs
c. Elevated troponin I & ECG
What risk factors does RMN have for a NSTEMI/IHD?
a. older age
b. male sex
c. hyperlipidemia, hypertension
d. renal insufficiency
e. prior MI (in 2007)
What treatment would you recommend for the NSTEMI? Drug regimens must
include drug, dose, frequency, route of administration and duration of therapy.
a.
What parameters would you monitor for efficacy and toxicity of the drug regimen
you recommend for RMN (both HCAP and NSTEMI)?

Bonus
Cefepime (cephalosporin) wide therapeutic index
No worries about accumulation and toxicity
So just start the new dose at 8am the next morning for convenience
Gentamicin or vancomycin narrower therapeutic index
May need to take levels of the drug first before deciding when to start the new dose

1. Describe the pharmacokinetic and pharmacodynamic changes that occur in the

elderly.
i. Absorption
1. Rate of oral absorption
a. GI motility
b. GI blood flow
2. Gastric pH
3. Extent of (oral) absorption
4. Transdermal absorption (rate & extent)
a. Drying of skin
b. Atrophy of epidermis & dermis
c. Blood perfusion
5. IM
a. Blood perfusion
b. Muscle mass
c. Unpredictable absorption difficult to give IM
ii. Distribution
1. Body water - decreased Vd for water soluble drugs
2. Muscle mass - decreased Vd for drugs that distribute into muscle
(digoxin)
3. Body fat - increased Vd for fat soluble drugs
4. Albumin - effect on drug binding if underlying illness and/or malnutrition
(no problem if healthy elderly)
5. 1-acid glycoprotein
iii. Metabolism
1. Liver size
2. Hepatic blood flow
3. Phase I (oxidation, reduction, hydrolysis)
4. Phase II (glucuronidation, sulfation, acetylation)
5. No effect on drug-induced inhibition/induction and genetic polymorphism
iv. Elimination
1. Renal blood flow
2. Renal tubular function
3. Glomerular filtration rate (GFR)
4. Decreased drug elimination
v. PD changes
1. Receptor sensitivity
a. Reduced response at -adrenergic receptors
i. Require higher concentrations of drug at receptor
ii. Eg -blockers, -agonists
b. Less dopaminergic neurons & receptors in CNS
i. More susceptible to EPS when taking anti-psychotics
2. Homeostatic control
a. Increased susceptibility to postural hypotension with antihypertensives
b. Increased risk of hypovolemia, hypokalemia, and hyponatremia from
diuretics
c. Increased sensitivity to warfarin
d. Increased sensitivity to drugs acting on CNS (opiates, benzodiazepines)
2. Define polypharmacy and describe the causes and consequences of polypharmacy
in the elderly.
i. 2 drugs up to 9 drugs (no consensus on number)
ii. Taking at least one drug that is not clinically indicated
iii. Consequences
1. Increased risk of

a. ADRs
b. DDIs
c. Hospitalisation
d. Being on inappropriate medications
2. Generally increased risk with increased number of drugs
3. Less adherence (with increased number of drugs)
3. Describe tools that can be used to optimize prescribing in the elderly and reduce
polypharmacy.
i. Med Reconciliation
ii. Identify all drugs that patient is taking
1. Including vitamins, supplements, OTC, herbal/TCM
2. Identify drugs by generic names
3. Check for compliance
4. Identify possible ADRs, DDIs
a. Discontinue if necessary
b. Helps to identify what drugs to avoid in the future
5. Look out for drugs with
a. No therapeutic benefit, no clear indication
b. Patient experiencing ADRs
c. Presence of safer alternative
6. Avoid treating ADRs with another drug increases number of drugs taken
(polypharmacy)
iii. Simplify medication regimen
1. Reduce risk of ADRs
2. Avoid non-compliance
3. While maintaining benefits
4. Define the concept of de-prescribing and describe the 5-step approach to deprescribing in the elderly.
i. Ascertain all drugs that patient is taking and indication for each drug
1. Check for non-compliance and reasons (eg financial, inconvenient, forget)
ii. Assess overall risk of drug therapy determines how aggressive de-prescribing
should be done
1. Number of drugs
2. Presence of high-risk drug (opioids, benzodiazepines, psychotropics, NSAIDs,
anticoagulants, digoxin, cardiovascular drugs, hypoglycemic agents, drugs
with anticholinergic effects)
1. Past or current toxicity
2. Age (>80yo)
3. Cognitive impairment
4. Substance abuse
5. Multiple comorbidities
6. Multiple prescribers
7. Past or current non-compliance
iii. For each drug, assess eligibility for discontinuation
1. No valid indication
2. Part of a prescribing cascade
3. Actual or potential harm outweighs potential benefit
4. Disease and/or symptom control is ineffective or symptoms have completely
resolved
5. Preventive drug unlikely to confer any important benefits over the patients
remaining lifespan
6. Drugs imposing unacceptable treatment burden
iv. Prioritise for discontinuation starting with drugs:
1. With the greatest harm and least benefit;

2. That are easiest to discontinue (eg lowest chance of withdrawal reactions or

disease rebound)
3. That the patient is most willing to discontinue first (to gain buy-in to
deprescribing other drugs)
4. Suggested approach is to rank drugs from high harm/low benefit to low
harm/high benefit and discontinue
v. Implement and monitor drug discontinuation programme
5. Discuss the factors that have been associated with non-adherence to medication in
the elderly, and describe interventions that have been shown to improve
adherence.
Identify all of the actual or potential medication-related problems in this patient.
Propose an action
plan to resolve each of the problems you identify. Include monitoring parameters in
your plan.

DDIs
o Omeprazole and Risedronate
o Proton Pump Inhibitors may diminish the therapeutic effect of Risedronate.
Increased risk of fractures when taking PPIs
o Proton Pump Inhibitors may increase the serum concentration of
Risedronate
Drugs that increase the pH in the stomach have the potential to
accelerate pH-sensitive dissolution of delayed-release risedronate
(enteric-coated)
o Consider switching or removing omeprazole
If possible, should investigate the reason why unable to eat and digest
food properly, and why nausea
Could be simple case of bloating, indigestion OTC products available
Could be ADR of levodopa nausea (3-30% incidence), can be relieved
by metoclopramide which she is already on
If acid-related cause of nausea, can switch to H2RA (eg ranitidine)
which does not have the same effect of diminishing therapeutic effect of
Risedronate
Monitoring: monitor for frequency and severity of episodes of nausea
after stopping/switching
o Risedronate should not be removed, important for osteoporosis.
ADRs
o Increased falls
Perhaps due to reduced mobility as a result of Parkinsons
Could also be due to orthostatic hypotension effect of
levodopa/carbidopa + worsened by antihypertensive agents (bisoprolol,
candesartan)
frequency and severity of episodes of orthostatic hypotension, frequency
of falls
o Hypotensive
Consider removing bisoprolol
Causing bradycardia (HR<60)
Causing hypotension
No indication no PMHx of HF, MI, AF
Can also remove candesartan
No indication no PMHx of HTN
Causing hypotension

Monitoring: BP
o Trazodone
May cause orthostatic hypotension and syncope
Not to be used in patients with glaucoma
Associated with higher risk of bone fractures (patient has osteoporosis)
Mood changes, suicidal thoughts (patient feels demoralized, to be safe,
stop before thoughts become suicidal)
Costs outweigh benefits consider removing
Monitoring: Insomnia
Betahistine
o Vertigo seems to be improved
o No important benefits if continued
o Should consider removing
o Monitoring: Any recurrence of vertigo episodes after removing
Watery and itchy eyes
o ADR of timolol
o Interferes with daily life.
o Should not remove timolol, important for glaucoma control
o Cetirizine tried but does not work
o Consider switching to another anti-histamine, eg: loratadine
o Monitoring: watery and itchy eyes, whether if it improves quality of life
Dimenhydrinate
o Strong anti-cholinergic activity (BEERS)
o Should avoid in elderly, glaucoma
Levodopa
o Use with caution with patients with narrow angle glaucoma
o However, levodopa necessary for parkinsons control
o Keep, but monitor intra-ocular pressure
Metoclopramide
o Dopamine receptor antagonists with potential to worsen parkinsonian
symptoms.
o BEERS criteria remove
Rosuvastatin
o Data on benefits of giving statins is for ischemic stroke
Not really for hemorrhagic strokes
o Low LDL levels (below ?)
o Should consider removing
Levodopa/carbidopa
o Possible ADRs experienced: nausea
o Not really causing falls or orthostatic hypotension
o Keep
o Perhaps after removing metoclopramide, may need to taper down dose
metoclopramide counteracts the action of levodopa if removed, may
become a levodopa overdose
Hypotension (77/50)
o Consider removing bisoprolol
Causing bradycardia (HR<60)
Causing hypotension
No indication no PMHx of HF, MI, AF
o Can also remove candesartan
No indication no PMHx of HTN

Causing hypotension
o Monitoring: HR, BP
Betahistine
o Vertigo seems to be improved
o Should consider removing or tapering off the dose
Risedronate
o Appropriate for osteoporosis
o On vitamin D but not on calcium should add calcium
Vitamin D
o Recommended daily dose 600-800IU
o Lower dose if possible
o Too high may cause nausea vomiting
Trazodone
o As a sedative: mirtazapine, escitalopram more used in elderly
o Should consider removing
Levothyroxine
o TSH is within normal range
o Continue same dose of levothyroxine
o Hypothyroidism signs and symptoms: fatigue may mask symptoms of
depression
If suspect depression, conduct thyroid function tests to confirm if
hypothyroidism
Omeprazole
o Nausea may be a ADR of other medications dont use drugs to treat side
effects of other drugs
o No PMHx of PUD, GERD, not on NSAIDs, antiplatelets no strong indications
for PPI
o Consider taking off
Metoclopramide
o Dopamine receptor antagonists with potential to worsen parkinsonian
symptoms. (BEERS)
o ADRs: Extrapyramidal symptoms
o If still needs a prokinetic can use domperidone (does not cross BBB into
CNS and cause EPS)
Timolol eye drops
o PMHx of glaucoma indication for timolol
o Used for 10 years
o Keep
Cetirizine
o Stop, because it may not be working against the watery and itchy eyes
o ADRs: dizziness, fatigue, dry mouth
Dimenhydrinate
o Used to treat nausea, which is a side effect of another drug
o ADRs: dry mouth, confusion, dizziness
o Stop
Non pharm
o Falls: refer to physiotherapist, occupational therapist to improve patients
balance
Vitamin B12
o Slightly low
o B12 supplements

Monitor diabetes
o Diabetes may cause gastroparesis
Monitor
o HR, BP
o Nausea vomiting
o ADRs
o Parkinsons disease
Walking: is it getting better or worsening