Cardiovascular Critical Care I

↓ CVP or PCWP

Preload

Afterload

Contractility

crystalloid/

colloid

raising

↑ PAP +/- ↑ HR

vasodilators

↓ BP/↑ HR

↓ BP

↑ BP +/- ↑ HR

antihypertensive

↓ CO/CI

Normotensive/Hypertensive

↓ BP/unresponsive

↓ HR (symptomatic +/- ↓ BP)

diuretic

fluid removal

adequate BP)

nitroprusside (if

adequate BP)

↑ CVP

↑ PCWP

Adapted from: Blais, DM. PSAP- IV: Critical and urgent care. 2010

Patient Case

Questions 1–8 pertain to the following case.

J.M. is a 68-year-old man with a history of CAD including STEMI 6 months ago with placement of two drug-

eluting stents, type 2 diabetes, hypertension, dyslipidemia, gastroesophageal reflux disease, obstructive sleep

apnea, frequent epistaxis, ischemic cardiomyopathy (LVEF 30%–35%), and moderate to severe mitral regurgi-

tation. He is admitted to the cardiac intensive care unit for severe shortness of breath and altered mental status,

and he is currently on continuous positive airway pressure (CPAP). He has gained 13 kg during the past 2 weeks

(now weighs 121 kg) and has had decreased urine output, despite having had his diuretic dose increased. Home

medications include the following: aspirin 81 mg once daily, ticagrelor 90 mg every 12 hours, pantoprazole 40

mg once daily, atorvastatin 40 mg once daily, insulin glargine 10 units every night, metformin 500 mg every 12

hours, furosemide 40 mg twice daily, and potassium chloride 20 mEq twice daily. His wife states that he was

taking clopidogrel until 1 month ago, at which time he was given ticagrelor samples from his primary care phy-

sician because of cost concerns. A physical examination reveals rales throughout his lung fields. He is afebrile,

anxious, and alert.

Given J.M.’s comorbidities, some drugs or drug classes have proven mortality benefits. Which medications

could be added or modified to the patient’s home medication profile to further slow disease progression and

improve mortality?