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An appropriate dose for this state of affairs assumed acute angina pectoris would be one initial metered dosage of 400 mcgs in order to alleviate the chest hurting experienced by the patient. If chest hurting has non been relieved after 5 proceedingss from this so a 2nd metered dosage should be administered but non more than these two doses are recommended ( Tam, 2006 ) .

The patient ‘s critical marks and history ( peculiarly medicines ) ?

There is a consideration to be made sing tolerance due to the patient ‘s old usage of GTN. Since tolerance to GTN has been demonstrated in clinical tests, in experience of occupational exposure and in stray research lab tissue experiments, intermittent therapy, such as demonstrated in the signifier of a sublingual spray, will cut down the likeliness of tolerance development ( Bond, 2002 ) .

2. Explain in point signifier:

The mechanism of action of GTN.


GTN is a powerful but short-acting nitrovasodilator.

-mtALDH ( mitochondrial aldehyde dehydrogenase ) catalyses NO ( azotic Oxide ) from GDN ( glyceryl dinitrate ) after denitration of GTN.

NO is an activator ( by heme-dependent mechanisms ) of CG ( guanylyl cyclase ) .

Resultant of this reaction is the forming of cGMP ( cyclic guanosine monophosphate ) from cGTP ( cyclic guanosine triphosphate ) .

cGMP protein kinase so causes the activation of myosin visible radiation concatenation phosphatase.

( Marsh & A ; Marsh, 2000 )

The physiological principle for administrating GTN ( i.e. what is the intended physiological result of administrating GTN ) .


The venas and arterias dilate with the debut of NO.

The dilation of the blood vass provide less opposition and later allows blood to be pumped more freely around the organic structure, alleviating the symptoms of the angina onslaught ( which is caused by excessively small O making the bosom, normally during exercising or effort and settees with remainder ) .

( Sandler, 1963 )

The principle for the sublingual path of disposal of GTN.


The sublingual path of disposal allowes glyceryl trinitrate to be more quickly absorbed by the oral cavity ‘s mucous membrane.

This action besides by-passes the liver to make the vascula system.

This allows more rapid alleviation from the hurting the patient is sing.

This sublingual attack of disposal can besides be used prophylactically before emotional emphasis, exposure to cold temperatures or physical effort.

( Farr, 1995 )

InterpretA the ECG shown in Figure 1 and supply your probationary diagnosing. What are your immediate conveyance considerations for Leonard?


Whilst it seems Leonard ‘s bosom rate has remained consistent ( the ECG in figure 1 demonstrates a bosom rate of approx. 80 beats per minute ) the 12-lead ECG shows that the rate of depolarization in Leonard ‘s fistula beat is non within normal scope ( Houghton, 1997 ) . The PR interval is really short ( 40ms, compared to an expected scope of 120-200ms ) . The QRS continuance is over 80ms although within normal scope and the QT interval is 120ms. This could connote that that repolarisation of the myocardium is non happening ( Hampden, 1992 ) .

Immediate conveyance considerations would be held at this point so as non to exercise any more emphasis on Leonard. It would be preferred to wait until 5 proceedingss after the initial dosage of GTN and if Leonard ‘s hurting has decreased so travel him instantly to the infirmary. If the hurting had non improved so continue with a 2nd dosage of GTN and so travel to the infirmary ( Chockalingam, et al. , 2000 ) .


Explain in point signifier:

The mechanism of action of acetylsalicylic acid relevant to this scene.


Predominantly involves the suppression of thrombocyte activation and exasperation.

Derives a possible antiplatelet consequence by barricading the coevals of thromboxane A2, caused by irreversibly demobilizing the COX-1 isoenzyme.

The activation of the coagulating cascade can play a critical function throughout the oncoming of acute occlusive vascular events.

Platelets, due to their deficiency of karyon, are a perfect mark for antithrombotic therapies and acetylsalicylic acid shows immediate and long-run effects on thrombocytes.

( Vane, 1990 )

The physiological principle for administrating acetylsalicylic acid in this scene ( i.e. what is the intended physiological result of administrating acetylsalicylic acid to a individual with Leonard ‘s clinical image ) .


In this case, an betterment of endothelial disfunction ( with the debut of acetylsalicylic acid, chewed to guarantee rapid curative blood degrees ) may:

Block the formation of COX-dependent vasoconstrictives ( which contribute to endothelial disfunction in coronary artery disease ) .

Reduce thrombosis and suppress the patterned advance of coronary artery disease.

Improve vasodilation and could cut down the inflammatory response in the event of coronary arteria disease.

( Lewis, et al. , 1983 )

Your considerations sing the suitability/safety of giving Leonard acetylsalicylic acid and the ground ( s ) for these considerations.


Aspirin may do bronchospasm in sick persons of asthma.

It may increase the effects of other hypoglycemic and anticoagulant drugs.

Should Leonard show symptoms of overdose so his legs should be raised from a supine place.

( Yusuf, et al. , 2001 )


Explain in point signifier:

The mechanism of action of clopidogrel.


Clopidogrel inhibits ADP-induced thrombocyte collection.

Besides inhibits collagen and thrombin-induced collection.

( Schomig, et al. , 1996 )

Absorption of clopidogrel by the bowel is followed by convertion by hepatic cytochrome P450 isoenzymes to an active thiol metabolite.

The active metabolite binds to the P2Y12 receptor.

The binding of ADP to the P2Y12 receptor is for good inhibited.

( Storey, et al. , 2001 )

The physiological principle for administrating clopidogrel.


Clopidogrel is a thienopyridine which acts as a non-competitive ADP receptor adversary.

It has antithrombotic effects similar to aspirin.

( Jernberg, et al. , 2006 )

Clopidogrel is more expensive than aspirin but more effectual in bettering cardiovascular complications in high hazard patients.

( Lev, et al. , 2007 )

When combined with acetylsalicylic acid, clopidogrel provides habit-forming decrease in the hazard of ischaemic events in patients with non-st-elevation ACS.

( Sabatine, et al. , 2005 )

The deductions of administrating clopidogrel prior to coronary angiography.


The danger of administrating clopidogrel before angiography is that internal hemorrhage may happen whilst the patient may necessitate coronary arteria beltway transplant ( Angiolillo, 2005 ) .

The clinical state of affairs where it would be inappropriate to administrate clopidogrel to Leonard.


If Leonard were allergic to clopidogrel.

If Leonard was sing any hemorrhage ( interally, in the signifier of ulcers, due to stomach jobs, etc. or externally ) .

If Leonard had an implicit in kidney or liver disease ( or any other status that may do shed blooding ) .

( Budaj A, et al. , 2002 )

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