Cardiovascular Week 2 Assignment

In reviewing multiple cardiovascular prescriptions and patient scenarios, several medication errors were identified that required correction to ensure clinical safety, appropriate dosing, and adherence to pharmacologic standards. The following analysis discusses these corrections in detail, offering clinical rationale and evidence-based recommendations aligned with current guidelines: Cardiovascular Week 2 Assignment.

Scenario 1: Prescription Review and Corrections

The original prescription for Hyzaar was written as “Hyzaar (losartan/hydrochlorothiazide) 50/25 mg PO daily #30 3 RF.” It lacked clarity in formatting and did not fully state the generic names. The corrected prescription should read: losartan 50 mg/hydrochlorothiazide 25 mg orally once daily. This order should authorize a 30-tablet dispense quantity with three refills.

This combination includes an angiotensin II receptor blocker (ARB) and a thiazide diuretic. Losartan prevents angiotensin II-mediated vasoconstriction, while hydrochlorothiazide promotes diuresis through sodium excretion in the distal tubule (Mulla & Siddiqui, 2022). The combination is effective for managing hypertension, particularly in individuals with volume overload.

The prescription for Lotrel was listed as “amlodipine/lisinopril 5/40 mg PO daily #30 3 RF.” The dosages are not typical for a fixed-dose product. The corrected prescription would be amlodipine 5 mg/lisinopril 20 mg orally once daily, with 30 tablets dispensed and three refills. This combination includes a calcium channel blocker and an angiotensin-converting enzyme (ACE) inhibitor.

Amlodipine induces vasodilation by reducing calcium entry into vascular smooth muscle, while lisinopril lowers vascular resistance by preventing angiotensin II formation (Yu et al., 2025). This therapeutic pairing is suitable for patients with hypertension and coexisting conditions like diabetes.

Another prescription error involved “hydralizine 25 mg PO QID #120 1 RF.” The drug name was misspelled, and “QID” should have been written out for clarity. The corrected order is hydralazine 25 mg orally four times daily. A 120-tablet quantity with one refill is appropriate.

Hydralazine is a direct vasodilator that reduces systemic resistance by relaxing arteriolar smooth muscle (Herman & Tivakaran, 2023). However, its use may result in reflex tachycardia or lupus-like symptoms with prolonged therapy, requiring careful monitoring.

The original digoxin prescription was “1.25 mg PO daily #30 1 RF,” which exceeds the usual therapeutic dose. The corrected version is digoxin 0.125 mg orally once daily, dispensed with 30 tablets and one refill. Digoxin is a cardiac glycoside that increases myocardial contractility by inhibiting the sodium-potassium ATPase pump, leading to increased intracellular calcium (David & Shetty, 2024). Due to its narrow therapeutic window, serum levels and renal function should be monitored closely.

Lastly, the prescription for Repatha was erroneously written as “140 mg IV every 2 weeks #1 1 RF.” The correct administration route is subcutaneous, not intravenous. The revised order is evolocumab (Repatha) 140 mg/mL by subcutaneous injection every two weeks, dispensed as one autoinjector with one refill.

Evolocumab, a PCSK9 inhibitor, prevents LDL receptor degradation, resulting in improved clearance of LDL cholesterol (Scheen et al., 2023). It is indicated for patients with familial hypercholesterolemia or statin intolerance.

Scenario 2: Fentanyl and First-Pass Metabolism

Fentanyl undergoes extensive hepatic first-pass metabolism when administered orally, reducing its systemic availability and rendering this route clinically ineffective (Ramos-Matos et al., 2021). For this reason, fentanyl is usually prescribed via alternative routes such as intravenous, transdermal, buccal, or intranasal delivery, which allow the drug to bypass the liver and provide effective systemic absorption.

In acute care, intravenous fentanyl is preferred due to its immediate onset. For chronic pain, a transdermal patch is effective because it maintains consistent plasma concentrations over time. A standard prescription is fentanyl 25 mcg/hour via a transdermal patch.

Patients are instructed to apply the patch to clean, non-irritated skin and rotate application sites every 72 hours. Ten patches are typically dispensed with no refills. This delivery method is intended for opioid-tolerant patients, and providers must monitor for side effects such as respiratory depression (Schiller & Mechanic, 2023).

Scenario 3: Cytochrome P450 Enzymes and Drug Metabolism

Cytochrome P450 (CYP450) enzymes are primarily located in the liver and are responsible for metabolizing the majority of pharmaceuticals. These enzymes also exist in smaller quantities in the lungs and gastrointestinal tract. Over 75% of all prescribed medications undergo CYP450-mediated metabolism (Zhao et al., 2021; Gilani & Cassagnol, 2023).

An example of a drug significantly affected by this pathway is carisoprodol, a centrally acting skeletal muscle relaxant. Identified by the imprint “292,” carisoprodol 350 mg is metabolized by CYP2C19 into meprobamate, which has sedative effects. Genetic polymorphisms or co-administered inhibitors of CYP2C19, such as omeprazole, may increase meprobamate levels, heightening the risk of sedation and dependency (Dean, 2021).

A recommended prescription for carisoprodol is 350 mg, taken orally three times daily and at bedtime. Dispensing a maximum of 90 tablets without refills and limiting use to two or three weeks is standard practice. Elderly patients should be carefully monitored due to the increased risk of falls and adverse CNS effects.

Scenario 4: Hyperlipidemia and Coronary Artery Disease Risk

The final scenario involves a 48-year-old male patient, referred to as DL, who presents with several cardiovascular risk factors. DL is a smoker, has a body mass index (BMI) of 31.97, and is currently being treated for type 2 diabetes using linagliptin. His lipid profile shows elevated levels across several parameters, with total cholesterol at 245 mg/dL, LDL cholesterol at 165 mg/dL, HDL cholesterol at 41 mg/dL, and triglycerides at 175 mg/dL.

According to the 2018 American College of Cardiology and American Heart Association guidelines, the goal lipid levels in a patient with high cardiovascular disease risk are as follows: total cholesterol < 200 mg/dL, LDL cholesterol < 100 mg/dL (or < 70 mg/dL in those at very high risk), HDL cholesterol > 40 mg/dL in men, and triglycerides < 150 mg/dL. Because DL has diabetes and an LDL level exceeding 160 mg/dL, he qualifies for high-intensity statin therapy.

One potential prescription would be atorvastatin 40 mg PO at bedtime. The patient should avoid concurrent intake of grapefruit juice, which can lead to increased serum concentration of the drug through CYP3A4 inhibition. Laboratory monitoring would include a lipid panel within 4 to 12 weeks of initiating therapy, then every 3 to 12 months.

Liver function tests should also be conducted at baseline and periodically, especially if symptoms of muscle pain or weakness are observed (Lala et al., 2023).

DL should also receive patient education on the benefits of lifestyle modifications. Smoking cessation is paramount to reducing his cardiovascular risk. He should also be encouraged to follow a heart-healthy diet such as the DASH or Mediterranean diet and engage in at least 150 minutes of moderate-intensity physical activity per week (Alexander et al., 2022). Regular monitoring of blood glucose and blood pressure should also be emphasized to optimize overall health outcomes.

DL presents with multiple risk factors for coronary artery disease, including his sex, age over 45, tobacco use, obesity, elevated LDL cholesterol, and type 2 diabetes. These factors place him in the high-risk category for cardiovascular events and justify the need for aggressive pharmacologic and lifestyle interventions.

References

Alexander, L., Christensen, S. M., Richardson, L., Ingersoll, A. B., Burridge, K., Golden, A., Karjoo, S., Cortez, D., Shelver, M., & Bays, H. E. (2022). Nutrition and physical activity: An Obesity Medicine Association (OMA) clinical practice statement 2022. Obesity Pillars, 1, 100005. https://doi.org/10.1016/j.obpill.2021.100005

David, M. N. V., & Shetty, M. (2024, November 25). Digoxin. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK556025/

Dean, L. (2021). Omeprazole therapy and CYP2C19 genotype (V. M. Pratt, H. L. McLeod, W. S. Rubinstein, S. A. Scott, L. C. Dean, B. L. Kattman, & A. J. Malheiro, Eds.). PubMed; National Center for Biotechnology Information (US). https://www.ncbi.nlm.nih.gov/books/NBK100895/

Gilani, B., & Cassagnol, M. (2023, April 24). Biochemistry, cytochrome P450. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK557698/

Herman, L. L., & Tivakaran, V. S. (2023). Hydralazine. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470296/

Lala, V., Minter, D. A., & Zubair, M. (2023, July 30). Liver function tests. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK482489/

Morieri, M. L., Perrone, V., Veronesi, C., Degli Esposti, L., Andretta, M., Plebani, M., Fadini, G. P., Vigili de Kreutzenberg, S., & Avogaro, A. (2021). Improving statin treatment strategies to reduce LDL-cholesterol: Factors associated with targets’ attainment in subjects with and without type 2 diabetes. Cardiovascular Diabetology, 20(1). https://doi.org/10.1186/s12933-021-01338-y

Mulla, S., & Siddiqui, W. J. (2022). Losartan. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK526065/

Ramos-Matos, C. F., Bistas, K. G., & Lopez-Ojeda, W. (2021). Fentanyl. PubMed; StatPearls Publishing. https://pubmed.ncbi.nlm.nih.gov/29083586/

Scheen, A., Wallemacq, C., & Lancellotti, P. (2023). Evolocumab (Repatha®): New therapy ofhypercholesterolaemia for secondary prevention of atherosclerotic disease. Revue Medicale de Liege, 78(10), 593–600. https://pubmed.ncbi.nlm.nih.gov/37830326/

Schiller, E. Y., & Mechanic, O. J. (2023). Opioid overdose. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK470415/

Taylor, K. P., & Goyal, A. (2023). Fentanyl transdermal. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK555968/

Yu, J. K., Gauen, A. M., Zmora, R., Petito, L. C., Kho, A. N., Smith, S. M., & Allen, N. B. (2025). Patient predictors of combination therapy as initial hypertension treatment: The AOURP (All of Us Research Program) registry. Journal of the American Heart Association. https://doi.org/10.1161/jaha.124.037626

Zhao, M., Ma, J., Li, M., Zhang, Y., Jiang, B., Zhao, X., Huai, C., Shen, L., Zhang, N., He, L., & Qin, S. (2021). Cytochrome P450 enzymes and drug metabolism in humans. International Journal of Molecular Sciences, 22(23), 12808. https://doi.org/10.3390/ijms222312808

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Pharmacology

To Prepare:

• Review the case study posted in “Announcements” by your Instructor for this Assignment
• Review the information provided and answer questions posed in the case study
• When recommending a medication, write out a complete prescription for the medication
• Whenever possible, use clinical practice guidelines in developing your answers when possible
• Include at least three references to support your answer and cite them in APA format.

DIRECTIONS:

For each of the scenarios below, answer the questions using your learning resources, Medscape, and clinical practice guidelines (ie JNC 8, AHA, ACC, etc). Lecturio is an optional resource but highly recommended. Be sure to thoroughly answer ALL questions. When recommending medications, write out a complete medication order.

 What would you send to a pharmacy? Include drug, dose, route, frequency, special instructions, # dispensed (days supply,) and refill information. Also state if you would continue, discontinue or taper the patient’s current medications. Review and discuss ALL labs and possible interactions.

Use at least 3 sources for each scenario and cite sources using APA format; include in-text citations. You do not need an introduction or conclusion paragraph. Please also review the assignment rubric.

Resources

• Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.). Elsevier.
  • Chapter 37, “Diuretics” (pp. 290–296)
  • Chapter 38, “Drugs Acting on the Renin-Angiotensin-Aldosterone System” (pp. 297–307)
  • Chapter 39, “Calcium Channel Blockers” (pp. 308–312)
  • Chapter 40, “Vasodilators” (pp. 313–315)
  • Chapter 41, “Drugs for Hypertension” (pp. 316–324)
  • Chapter 42, “Drugs for Heart Failure” (pp. 325–336)
  • Chapter 43, “Antidysrhythmic Drugs” (pp. 337–348)
  • Chapter 44, “Prophylaxis of Atherosclerotic Cardiovascular Disease” (pp. 349–363)
  • Chapter 45, “Drugs for Angina Pectoris” (pp. 364–371)
  • Chapter 46, “Anticoagulant and Antiplatelet Drugs” (pp. 372–388)

Notes:

• Please see attached the grading rubric.
• Please check and include all the requirements highlighted in the rubric