Case Study 2 (Cardiovascular system)
John Doe is a 28 year-old who recently subscribed to a new HMO (managed health care provider). Records from his previous health care providers indicated generally good health for Mr. Doe, although documented that he suffered from Wolff-Parkinson-White (WPW) syndrome. His physical examination on entry to the new HMO showed normal blood pressure (122/78) and resting heart rate (NSR, 71). His initial screening lab values all came back normal. His only complaint upon examination was recurrent headaches.
According to records, approximately one month ago, John Doe complained that treatment with the usual anti-migraine therapies was not effective. His physician placed him on amitriptyline, 10mg to be administered daily at bedtime. Each subsequent week the dosage was to be increased according to the following schedule: 20mg/day during week two, 50mg/day during week three, and most recently, 100mg/day in this final week. According to his wife, Mr. Doe’s headaches were not as severe, but he had not yet returned to his physician for a follow-up visit.
Two days ago, Mr. Doe was playing softball in a league in which he has competed for several years. During a particularly challenging play in the outfield he sprinted toward a fly ball, leapt into the air, and made a fantastic catch, falling to the ground on his back. He got up, threw the ball back to the infield with high accuracy, and then immediately collapsed to the ground. When his teammates reached him in the outfield, there was no pulse. One of the team members administered CPR while the others called 911. Paramedics arrived within five minutes of the ordeal, but were unsuccessful in their attempts to revive John Doe.
A thorough autopsy of Mr. Doe revealed no apparent cause of death. There was no evidence of stroke, myocardial infarction, or traumatic injury.
According to the number of tablets dispensed, as well as the number remaining, John Doe was apparently compliant in taking the medication as prescribed by his physician.
The only drugs present in the postmortem cardiac blood were caffeine (barely detectable), amitriptyline (0.05mg/liter), and nortriptyline (0.05mg/liter). A screen for controlled substances (illegal drugs) was negative.
While you are more than welcome to request additional information from John Doe’s file, please consider that such materials are likely very limited given that this is a postmortem case. Please respond to the following questions using only a paragraph or two for each answer.
1. Please comment on the use of amitriptyline for the treatment of John Doe’s headache.
2. Were the doses or dosing schedule unusual or noteworthy?
3. Is there any reason to suspect abnormal drug metabolism in Mr. Doe? How do you support your answer?
4. Do you think that amitriptyline had anything to do with the patient’s death? If so, please explain what happened to cause his death. Provide evidence to support your answer.
5. If you think that the drug contributed significantly to, or caused the death of John Doe, do you think that his health care providers deviated from a reasonable standard of care? Why or why not?
6. If you think that amitriptyline did NOT contribute significantly to the death of Mr. Doe, please provide an alternative explanation for sudden death in an apparently healthy 28 year-old male, as well as evidence to support your position.
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