What is the treatment for a patient with Plasmodium falciparum (Pf) positive malaria and anterolateral ischemia, without chest complaints or dyspnea?

From the Guidelines

The patient with Plasmodium falciparum malaria and anterolateral ischemia without chest complaints or dyspnea should be treated with artemisinin-based combination therapy (ACT) such as artemether-lumefantrine or dihydroartemisinin-piperaquine for the malaria infection, and aspirin, a statin, and appropriate antihypertensives for the cardiac ischemia. The treatment regimen for the malaria infection should follow the guidelines outlined in the most recent study 1, which recommends the use of ACTs as the first-line treatment for uncomplicated P. falciparum malaria. The cardiac ischemia should be managed with:

• Aspirin 81-325 mg daily
• A statin such as atorvastatin 40-80 mg daily
• Appropriate antihypertensives if indicated. Close cardiac monitoring is essential, as malaria can exacerbate cardiac conditions through systemic inflammation, microvascular obstruction, and metabolic derangements 1. Antimalarial medications like chloroquine and halofantrine should be avoided due to potential QT prolongation. The patient should be hospitalized for observation of both conditions, with frequent monitoring of parasitemia levels, ECG changes, cardiac enzymes, and vital signs. Adequate hydration and electrolyte balance must be maintained, as dehydration and electrolyte abnormalities can worsen both conditions 1. It is also important to note that the treatment of severe falciparum malaria may require intravenous artesunate 2.4 mg/kg at 0,12,24, and 48 hours, as recommended in the guidelines 1. Overall, the treatment plan should prioritize the management of both the malaria infection and the cardiac ischemia, with close monitoring and adjustment of the treatment regimen as needed to ensure the best possible outcome for the patient.

From the FDA Drug Label

1 INDICATIONS AND USAGE Quinine sulfate capsules are an antimalarial drug indicated only for treatment of uncomplicated Plasmodium falciparum malaria. Quinine sulfate has been shown to be effective in geographical regions where resistance to chloroquine has been documented [ see Clinical Studies (14)] Limitations of Use: Quinine sulfate oral capsules are not approved for: Treatment of severe or complicated P. falciparum malaria. Prevention of malaria. Treatment or prevention of nocturnal leg cramps [ see Warnings and Precautions (5.1)].

The treatment for a patient with Plasmodium falciparum (Pf) positive malaria and anterolateral ischemia, without chest complaints or dyspnea, is quinine sulfate capsules. The recommended dosage is 648 mg (two capsules) every 8 hours for 7 days. However, it is essential to note that quinine sulfate is only indicated for the treatment of uncomplicated P. falciparum malaria. If the patient's condition is severe or complicated, alternative treatments should be considered. Additionally, the patient should be monitored closely for adverse effects, particularly thrombocytopenia and hemolytic-uremic syndrome/thrombotic thrombocytopenic purpura (HUS/TTP) 2.

It is also important to consider the use of proguanil in combination with atovaquone for the treatment of uncomplicated P. falciparum malaria, as it has shown high efficacy rates in clinical trials 3. However, the specific treatment regimen should be determined based on the patient's individual needs and medical history.

From the Research

Treatment for Pf Positive Malaria with Anterolateral Ischemia

• The treatment for a patient with Plasmodium falciparum (Pf) positive malaria and anterolateral ischemia, without chest complaints or dyspnea, typically involves the use of artemisinin-based combination therapies (ACTs) 4, 5, 6.
• ACTs are recommended as the first-line treatment for uncomplicated falciparum malaria due to their efficacy and ability to prevent the development of resistance 5, 6.
• Examples of ACTs include artemether-lumefantrine, artesunate-mefloquine, and dihydroartemisinin-piperaquine, with efficacy rates usually exceeding 95% 6.
• The choice of ACT may depend on various factors, including the patient's medical history, the presence of any concomitant illnesses, and the potential for drug interactions 7, 8.

Considerations for Anterolateral Ischemia

• Anterolateral ischemia may require additional consideration in the treatment of Pf positive malaria, as it can increase the risk of cardiac complications 7.
• The use of certain ACTs, such as artenimol + piperaquine, may be associated with a higher risk of cardiac adverse events due to their potential to prolong the QT interval 7.
• Therefore, the selection of an ACT should take into account the patient's cardiovascular risk factors and the potential for drug interactions 7, 8.

Treatment Recommendations

• Based on the available evidence, artemether-lumefantrine or artesunate-mefloquine may be suitable options for the treatment of Pf positive malaria with anterolateral ischemia, without chest complaints or dyspnea 4, 5, 6.
• However, the final treatment decision should be made on a case-by-case basis, taking into account the individual patient's needs and medical history 8, 6.