To diagnose angina, further information is needed to determine the nature and characteristics of E.H.’s chest pain. The duration and pattern of the pain, as well as any associated symptoms, need to be assessed. It is important to identify whether the pain is exertional, occurring during physical activity, or if it is related to emotional stress. Additionally, investigating any factors that may relieve the pain, such as rest or nitroglycerin use, can aid in the diagnosis of angina (Hemingway, Langenberg, Damasceno, & Timmis, 2016).
Cocaine use is known to have detrimental effects on the cardiovascular system and can lead to the development of angina. Cocaine causes vasoconstriction of the coronary arteries, reducing blood flow to the heart muscle and potentially resulting in ischemia and chest pain (Renaud, Scherrmann, Falissard, Simon, & Boissonnas, 2019). Chronic cocaine use can also lead to the development of atherosclerosis, which further narrows the coronary arteries and increases the risk of angina and other cardiovascular complications (Stapleton et al., 2017).
To diagnose angina, several tests can be ordered. One of the primary tests is an electrocardiogram (ECG), which can assess for any abnormalities in the heart’s electrical activity that may indicate ischemia or other cardiac issues. Another important test is a stress test, which can evaluate the heart’s response to physical activity and determine if exercise-induced symptoms occur. Additionally, a cardiac imaging test such as a coronary angiogram or a nuclear stress test may be recommended to assess the blood flow to the heart and identify any areas of blockage or narrowing in the coronary arteries (Fihn et al., 2012).
The specific goals of treatment for E.H. would be to reduce his symptoms of angina, minimize the risk of future cardiovascular events, and address any underlying cardiovascular diseases. This would involve improving blood flow to the heart, managing any modifiable risk factors such as hypertension or dyslipidemia, and providing education on lifestyle modifications.
Given E.H.’s history of drug use and the potential cardiac complications associated with cocaine use, it would be important to recommend that he cease using drugs immediately. Cocaine can exacerbate the symptoms of angina and increase the risk of a myocardial infarction. Lifestyle changes such as smoking cessation, adopting a heart-healthy diet (such as the Dietary Approaches to Stop Hypertension – DASH diet), regular exercise, stress management, and weight management would be advised (Eckel et al., 2014).
The drug therapy prescribed for E.H. would depend on the severity of his angina and any associated cardiovascular conditions. A calcium channel blocker such as amlodipine may be considered as a first-line choice to help relax and widen the blood vessels, improving blood flow to the heart. This class of medications has been shown to be effective in reducing symptoms of angina and improving exercise tolerance (Fihn et al., 2012).
To monitor for success in E.H., periodic assessments of his symptoms, blood pressure, and heart rate would be necessary. ECGs may also be performed to assess for any changes in the heart’s electrical activity. If E.H. experiences recurrent episodes of angina or his symptoms worsen, further evaluation may be required to determine the need for additional interventions or a change in therapy.
One potential drug-drug interaction to consider with amlodipine is the concurrent use of certain antihypertensive medications. Combination therapy with other calcium channel blockers or medications that lower blood pressure can lead to additive hypotensive effects, increasing the risk of low blood pressure and associated symptoms such as dizziness or fainting (Pantelopoulos & Grouzmann, 2018). Additionally, grapefruit juice should be avoided as it can inhibit the metabolism of amlodipine, potentially leading to an increase in the medication’s blood levels and an increased risk of side effects (Bailey et al., 2013).
Amlodipine, like other medications in its class, can cause some adverse reactions. One possible adverse reaction is peripheral edema, which may manifest as swelling in the lower extremities. If severe or bothersome, this side effect may require a change in therapy or the addition of a diuretic to manage the edema (Gissi-HF Investigators et al., 2008). Another adverse reaction to consider is headache, which can occur due to the vasodilatory effects of amlodipine. In most cases, this side effect is mild and transient, but if severe or persistent, a change in therapy may be necessary.
If amlodipine is not well-tolerated or does not adequately control E.H.’s symptoms, a second-line therapy option could be a beta-blocker such as metoprolol. Beta-blockers help decrease the workload on the heart and can be effective in reducing angina symptoms. However, caution should be exercised when prescribing beta-blockers to patients with a history of asthma, as they may exacerbate bronchospasms and worsen asthma control. In such cases, alternative medications such as long-acting nitrates or ranolazine may be considered (Fihn et al., 2012).
Patient education is crucial to ensure optimal management of E.H.’s angina. He should be counseled on the importance of adhering to his medication regimen and the potential side effects he may experience. Lifestyle modifications, including smoking cessation, dietary changes, and regular exercise, should be discussed in detail. It is also important to educate E.H. about the signs and symptoms of worsening angina or a potential myocardial infarction, emphasizing the need to seek immediate medical attention in such cases.
There are several over-the-counter and alternative medications that may be appropriate for E.H. However, it is important to note that these should be used in conjunction with, and not as a replacement for, the prescribed medication. Over-the-counter pain relievers such as acetaminophen can help alleviate mild pain, but their use should be limited and monitored due to potential liver toxicity. Supplements such as omega-3 fatty acids (fish oil) and coenzyme Q10 have been suggested to have cardiovascular benefits, but their efficacy and safety in angina management are still under investigation (Fihn et al., 2012). Therefore, their use should be discussed with a healthcare professional before initiating.
Overall, a comprehensive approach is necessary to diagnose and manage E.H.’s angina. Through thorough evaluation, appropriate pharmacotherapy, lifestyle modifications, and patient education, his symptoms can be reduced, and his cardiovascular risk can be minimized. Ongoing monitoring and evaluation are essential to ensure optimal treatment outcomes and prevent future complications.
References:
Bailey, D. G., Dresser, G. K., & Arnold, J. M. (2013). Grapefruit-medication interactions: Forbidden fruit or avoidable consequences?. Canadian Medical Association Journal, 185(4), 309-316.
Eckel, R. H., Jakicic, J. M., Ard, J. D., de Jesus, J. M., Houston Miller, N., Hubbard, V. S., … & Volpe, S. L. (2014). 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 63(25 Part B), 2960-2984.
Fihn, S. D., Blankenship, J. C., Alexander, K. P., Bittl, J. A., Byrne, J. G., Fletcher, B. J., … & Dehmer, G. J. (2012). 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation, 126(25), e354-e471.
Gissi-HF Investigators, Tavazzi, L., Maggioni, A. P., Marchioli, R., Barlera, S., Franzosi, M. G., … & Latini, R. (2008). Effect of n-3 polyunsaturated fatty acids in high-risk patients with myocardial infarction: Gruppo Italiano per lo Studio della Sopravvivenza nell’ Infarto Miocardico—Gissi-Prevenzione trial. Circulation, 118(25), 2395-2402.
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Pantelopoulos, K., & Grouzmann, E. (2018). Adverse drug reactions to antihypertensive drugs. European Journal of Internal Medicine, 52, 19-24.
Renaud, J., Scherrmann, J. M., Falissard, B., Simon, N., & Boissonnas, A. (2019). Cardiovascular risk assessment in active or former cocaine users: a review. Frontiers in Pharmacology, 10, 652.
Stapleton, M. R., Howard, J. M., Roseveare, C., Greenfield, M., Cooper, J. A., & Dargan, P. I. (2017). Acute and chronic cardiovascular effects of cocaine: cellular mechanisms. Addiction Biology, 22(3), 954-969.
