Medical Practitioner, Dr E New Zealand Men's Clinic - Health and ...

Health and Disability Commissioner
found effective. His background co-morbidities include hypertension, and
ischaemic heart disease. He has had 3 vessel CABG and an aortic valve
replacement (tissue not prosthetic). His medications include Verapamil, Lipex,
Progout, Enalapril, Aspirin and Somac.
[Mr C] was recommended injection therapy which he refused. He was then
prescribed a nasal spray. This then becomes quite confusing. The consent form is
for apomorphine/phentolamine spray. The receipt is for
apomorphine/phentolamine sublingual tablets, which I understand were
unavailable. [Dr E] avers that he prescribed only apomorphine and not
phentolamine.
On taking the medication [Mr C] suffered what appears to be a severe hypotensive
episode.
I would consider in this case that [Dr E’s] history taking, note taking and
examination to be inadequate. Previously I have mentioned that with injection
therapy which is confined to the cavernosa that blood pressure recordings etc do
not alter treatment or outcomes. This is true. It is not true when prescribing a
systemically vasoactive oral or nasal medication. These medications have the
potential to lower blood pressure, it is therefore prudent to know what the baseline
pressure is. The patient’s aortic valve (tissue) may be stenotic, which would reduce
the patient’s ability to increase cardiac output to compensate for hypotension.
Failure to maintain adequate cardiac output in a patient with ischaemic heart
disease could have serious consequences.
In my opinion there is insufficient history recorded as to the current cardiac status
regarding angina, exercise tolerance etc. This does not mean it was not elicited,
merely that it was not recorded. I am unable to comment which is the case.
Similarly cardiac auscultation should have been used to assess degree of aortic
stenosis and cardiac referral would be warranted if there were concerns on a
clinical basis. I do not accept that a cardiologist referral/discussion is a mandatory
standard of care as stated by Dr Tiller. Blood pressure should have been assessed.
Verapamil and Enalapril are both likely to potentiate the first dose effect of an
alpha blocker such as phentolamine. This would produce a hypotensive episode
such as that seen in [Mr C’s] case. I would consider it imprudent to prescribe
phentolamine in the presence of these other medications. There is some
discrepancy as to what was prescribed and dispensed.
Apomorphine can also cause hypotension and its use in unstable coronary disease
is not recommended. There are insufficient notes recording the status of [Mr C’s]
coronary disease to comment on the appropriateness of apomorphine here. It is
recommended that oral Apomorphine use be initiated in a monitored hospital
situation. I have no information on the pharmacodynamics of this nasal spray and
cannot reliably comment therefore on how it is best initiated. Nausea is a common
18 December 2008 40
Names have been removed (except the NZ Men’s Clinic) to protect privacy. Identifying letters are
assigned in alphabetical order and bear no relationship to the person’s actual name.