734
P A R T 8
Drugs acting on the cardiovascular system
CRITICAL THINKING SCENARIO
Treating hyperlipidaemia
THE SITUATION
M.M., a 55-year-old Caucasian businessman, was seen for a
routine insurance physical examination. He was found to be
obese and borderline hypertensive, with a non-fasting low-
density lipoprotein (LDL) level of above 4.0 mmol/L (very
high). M.M. reported smoking two packs of cigarettes a day
and noted in his family history that both of his parents died
of heart attacks before the age of 50. He described himself
as a “workaholic” with no time to exercise and a tendency
to eat most of his meals in restaurants. The primary medical
regimen suggested for M.M. included ceasing or decreasing
smoking, weight loss, dietary changes to eliminate
saturated fats and decreased stress. On a return visit after
4 weeks, M.M. had lost 3.5 kg and reported a decrease in
smoking, but his LDL levels were unchanged. The use of an
antihyperlipidaemic drug was discussed. He was started on
atorvastatin and advised to continue the diet and exercise
program and to return in 3 months for follow-up.
CRITICAL THINKING
What care interventions are appropriate at this point?
Consider all of the known risk factors for coronary artery
disease
(
CAD
)
; then rank M.M’s risk based on those factors.
What lifestyle changes can help M.M. to reduce his risk of
heart disease?
What support services should be consulted to help M.M.?
Should other tests be done before considering any drug
therapy for M.M.?
Think about the kind of teaching that
would help M.M. to cope with the overwhelming lifestyle
changes that have been suggested, yet remain compliant
with his medical regimen.
DISCUSSION
M.M.’s description of himself as a workaholic should alert
the healthcare provider to the possibility that he will have
trouble adapting to any prescribed lifestyle changes.
(Workaholics tend to be very organised, goal-driven
and somewhat controlling individuals.) M.M. should first
receive extensive teaching about CAD, his risk factors and
his options. The benefits of decreasing or eliminating risk
factors should be discussed. Drug therapy is intended as
an adjunct to diet and exercise, and the effectiveness of
drug therapy improves remarkably when diet and exercise
changes are made. M.M. may be more compliant if he
exercises some control over his situation, so he should be
invited to suggest possible lifestyle changes or adaptations.
M.M. also should be encouraged to set short-range goals
that are achievable, to help him feel successful. He needs
to understand that beginning drug therapy does not mean
that exercise and diet are no longer important.
M.M. also needs to understand that antihyperlipidaemic
drugs can cause dizziness, headaches, gastrointestinal
upset and constipation. Because of his busy lifestyle, M.M.
may have trouble coping with these adverse effects. M.M.’s
healthcare provider may need to try a variety of different
drugs or combinations of drugs to find ones that are
effective but do not cause unacceptable adverse effects.
The Australian National Heart Foundation has
numerous booklets, diets, support groups and counsellors
who can help M.M. as he tries to adapt to his medical
regimen. He can contact the Foundation online at
for a quick reference and
referrals to other sources. M.M. will benefit from having
a consistent healthcare provider who can offer him
encouragement, answer any questions and allow him to
vent his feelings. Often, lifestyle changes are the most
difficult part of this medical regimen, so M.M. will need
constant support.
CARE GUIDE FOR M.M.: HMG-CoA REDUCTASE
INHIBITORS
Assessment: History and examination
Assess M.M.’s health history for allergies to any HMG-CoA
reductase inhibitor or fungal byproducts; hepatic
dysfunction; or endocrine disorders.
Focus the physical examination on the following areas:
Cardiovascular: blood pressure, pulse, perfusion
Neurological (CNS): orientation, affect, reflexes, vision
Skin: colour, lesions, texture
Respiratory system: rate, adventitious sounds
GI: abdominal examination, bowel sounds
Laboratory tests: liver and renal function tests, serum lipids
Implementation
Administer the drug at bedtime.
Monitor serum lipids prior to therapy and periodically
during therapy.
Provide comfort and safety measures: Give small meals.
Arrange for periodic ophthalmic examinations to screen for
cataracts.
Give the drug with food if GI upset occurs.
Institute bowel program as needed.
Provide safety measures if needed.
Monitor liver function, and arrange to stop the drug if liver
impairment occurs.
Provide support and reassurance to deal with drug effects
and the need to make lifestyle, diet and exercise
changes.
Provide teaching regarding drug, dosage, adverse effects,
what to report and safety precautions.
