Case Study of Unstable Angina Pectoris (UAP) Post Percutaneous Transluminal Coronary Angioplasty (PTCA) with Controlled Hypertension Comorbidity, Dyspepsia Syndrome, and Stage 1 Acute Kidney Injury (AKI) in Patients in the Heart Ward

Abstract

This case study aimed to evaluate the appropriateness of pharmacotherapy, identify potential Drug Related Problems (DRPs), and provide rational therapy recommendations for a patient with UAP post PTCA 1 stent, controlled hypertension, dyspepsia syndrome, and Acute Kidney Injury (AKI) stage 1 dd acute on Chronic Kidney Disease (CKD). A descriptive method with a case study design was applied to a 53-year-old male patient hospitalised in the Cardiac Ward of RSUP Dr. M. Djamil Padang. Data were collected prospectively through interviews, clinical observation, and medical record review, then evaluated based on the right indication, right patient, right drug, and right dose criteria and compared with clinical guidelines. The results showed that the therapy, comprising antiplatelet, anticoagulant, statin, nitrate, antihypertensive, gastrointestinal, and supportive agents, was generally appropriate. However, several potential DRPs were identified, namely lower-than-reference doses of enoxaparin, ranitidine, and lactulose, as well as pharmacodynamic interactions among acetosal, clopidogrel, and enoxaparin that increase bleeding risk. During follow-up, the patient's clinical condition and renal function improved, indicated by a decrease in creatinine from 1.5 to 1.1 mg/dL and urea from 28 to 15 mg/dL. Pharmacist involvement in medication review is essential to optimise therapeutic effectiveness and safety.