Module X: Hypertension/Heart Failure Discussion
A 50yo African American woman presents to clinic feeling tired for the last 3 months. She also has trouble breathing when walking 2-3 blocks. She sleeps on 2 pillows at night to help with her breathing. PMH: HTN, arthritis. Physical exam: edema present in both feet. Medications: HCTZ 12.5mg daily, verapamil SA 120 mg daily, ibuprofen 200 mg BID for arthritis in knee. Vitals: height 5’2″, 63kg, BP 134/84, HR 78, EF 30% per echocardiogram. Her labs are normal including a creatinine of 1.1. She denies chest pain or palpitations. Her EKG reveals normal sinus rhythm with no evidence of ischemia or recent acute coronary syndrome Hypertension/Heart Failure Discussion Essays.
- How would you classify her heart failure?
- What changes (modifications, additions, deletions) to her medications do you recommend that will:
- Improve her symptoms?
- Impact long term outcomes?
- What monitoring parameters do you recommend?
- What non-pharmacologic recommendations do you have?
Post your initial response by Wednesday at midnight. Respond to one student by Sunday at midnight. Both responses should be a minimum of 150 words, scholarly written, APA formatted, and referenced. A minimum of 2 references are required (other than your text). Refer to the Grading Rubric for Online Discussion in the Course Resource section.
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Our patient is endorsing symptoms of increased fatigue, shortness of breath with ordinary physical activity, edematous feet, orthopnea, and Stage 1 hypertension. This symptomatology is consistent with a diagnosis of heart failure Stage C (SCHF) Class II with reduced ejection fraction (Yancy et al., 2018). Heart failure with reduced ejection fraction is also referred to as systolic heart failure (Saltzberg, 2016). The endorsement of orthopnea is suggestive of congestion behind the ventricle, i.e. congestive heart failure. These symptoms also suggest acute heart failure. As this patient has a primary medical history of hypertension and arthritis, it can be assumed that a diagnosis of heart failure would be new for her. A more thorough medical and social history is necessary to create a treatment plan. It would be helpful to ask the patient if she coughs frequently, smokes, drinks alcohol, or has a family history of heart disease Hypertension/Heart Failure Discussion Essays.
Heart failure results from various functional and/or structural defects in the myocardium. These defects result in a dysfunctional filling of the ventricles or ejection of blood (Inamdar & Inamdar, 2016). These defects can result in decreased perfusion to the heart or an increased hemodynamic overload. A major part of this underlying pathology is related to chronic inflammation, the dynamics of which may or may not be known. Typical manifestations of left side heart failure include shortness of breath, crackles or diminished lung sounds, presence of a third heart sound or “gallop”, decreased urinary output, edema in the extremities, and dyspnea (Inamdar & Inamdar, 2016).
In this scenario, the patient is prescribed HCTZ and verapamil. Research suggests that calcium channel blockers, such as verapamil, may worsen heart failure in patients with decreased ejection fraction (Zaremski et al., 2018). Hydrochlorothiazide (HCTZ), while known to be effective for hypertension, is not effective as monotherapy for a patient with symptomatic heart failure such as this patient (James et al., 2014). As such, both verapamil and HCTZ should be discontinued. The gold standard for heart failure is an angiotensin-converting enzyme inhibitor (ACE inhibitor), such as lisinopril or captopril. However, some evidence suggests that ACE inhibitor use in African Americans increases the risk of angioedema (Yancy et al., 2018). However, this risk is only 0.5%, so an ACE inhibitor is still the recommended antihypertensive for SCHF. The patient should be started on 1 of 3 beta blockers proven to reduce morality: metoprolol, bisoprolol, or carvedilol (Saltzberg, 2016). A loop diuretic, such as furosemide, is also recommended as the patient has edematous feet (Lloyd-Jones et al., 2017). An additional option for the patient, as she is an African American, could be the combination of hydralazine and isosorbide dinitrate, which is recommended to reduce morality in this population (Saltzberg, 2016). While ARNIs, such as sacubitril/valsartan were recently approved for patients with symptomatic HFrEF, evidence-based practice suggests these should be second line and reserved for patients unable to take ACE inhibitors or ARBs as ARNIs are expensive and have an increased risk of hypotension (Inamdar & Inamdar, 2016). As a clinician, I would start this patient on lisinopril 5 mg once daily, furosemide 20 mg once daily, metoprolol 25 mg once daily, and bi-weekly potassium 20 mg. The patient should be seen again in two weeks to evaluate effectiveness of therapy and plan to increase dosage as the patient is being started on low initial doses Hypertension/Heart Failure Discussion Essays. The patient should be taught to weigh herself daily at the same time and record that weight. The goal for the patient is a weight loss of up to 2 pounds per day (Yancy et al., 2018). The patient should have regular monitoring of electrolytes and kidney function to ensure sodium and potassium are within normal limits and because ACE inhibitors can worsen renal function. A serum creatinine should be included as ACE inhibitors can potentially increase this number.
While medications are helpful in managing heart failure, there are lifestyle modifications that should be included as well. The patient should be instructed to decrease sodium intake to no more than 2 g/day, limit water intake to 2 liters per day, and follow the American Heart Association Step 2 Diet (American Heart Association, 2017). Light to moderate exercise should be incorporated. Swimming, walking, and bike riding would be excellent choices. Finally, the patient should be instructed not to smoke or drink alcohol and to consider utilizing acetaminophen for pain instead of ibuprofen, as NSAIDS can exacerbate heart failure (James et al., 2014).
There are quite a few positive outcomes expected of this change. These include a decrease in the endorsement of shortness of breath upon exertion in addition to orthopnea. The patient should also notice a decrease in edema in her feet as well as feeling less fatigued. The patient may also lose weight related to her healthy lifestyle Hypertension/Heart Failure Discussion Essays.
References
American Heart Association. (2017, August 15). The American Heart Association diet and lifestyle recommendations. http://www.heart.org/en/healthy-living/healthy-eating/eat-smart/nutrition-basics/aha-diet-and-lifestyle-recommendations
Inamdar, A., & Inamdar, A. (2016). Heart failure: Diagnosis, management and utilization. Journal of Clinical Medicine, 5(7), 62. https://doi.org/10.3390/jcm5070062
James, P. A., Oparil, S., Carter, B. L., Cushman, W. C., Dennison-Himmelfarb, C., Handler, J., Lackland, D. T., LeFevre, M. L., MacKenzie, T. D., Ogedegbe, O., Smith, S. C., Svetkey, L. P., Taler, S. J., Townsend, R. R., Wright, J. T., Narva, A. S., & Ortiz, E. (2014). 2014 evidence-based guideline for the management of high blood pressure in adults. JAMA, 311(5), 507. https://doi.org/10.1001/jama.2013.284427
Lloyd-Jones, D. M., Morris, P. B., Ballantyne, C. M., Birtcher, K. K., Daly, D. D., DePalma, S. M., Minissian, M. B., Orringer, C. E., & Smith, S. C. (2017). 2017 focused update of the 2016 acc expert consensus decision pathway on the role of non-statin therapies for ldl-cholesterol lowering in the management of atherosclerotic cardiovascular disease risk. Journal of the American College of Cardiology, 70(14), 1785–1822. https://doi.org/10.1016/j.jacc.2017.07.745
Saltzberg, M. (2016). 2016 update to heart failure clinical practice guidelines. American Heart Association. http://www.heart.org/idc/groups/heart-public/@wcm/@mwa/documents/downloadable/ucm_489089.pdf
Yancy, C. W., Januzzi, J. L., Allen, L. A., Butler, J., Davis, L. L., Fonarow, G. C., Ibrahim, N. E., Jessup, M., Lindenfeld, J., Maddox, T. M., Masoudi, F. A., Motiwala, S. R., Patterson, J., Walsh, M., & Wasserman, A. (2018). 2017 acc expert consensus decision pathway for optimization of heart failure treatment: Answers to 10 pivotal issues about heart failure with reduced ejection fraction. Journal of the American College of Cardiology, 71(2), 201–230. https://doi.org/10.1016/j.jacc.2017.11.025
Zaremski, L., Kargoli, F., Waqas, H., Bulcha, N., Leiderman, E., Nevelev, D., Chudow, J., Shah, T., Fisher, J. D., Biase, L., Krumerman, A., & Ferrick, K. (2018). Mortality associated with calcium channel blockers in heart failure with reduced ejection fraction: Real world experience. Journal of the American College of Cardiology, 71(11), A472. https://doi.org/10.1016/s0735-1097(18)31013-1 Hypertension/Heart Failure Discussion Essays
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I would classify this particular patient in New York Heart Association (NYHA) functional classification as class II heart failure and as stage C in American College of Cardiology/American Heart Association (ACC/AHA) staging criteria. I see this woman being functional and mildly limited since she can walk 2-3 blocks before having trouble breathing. Chisolm-Burns et al. (2019) describes the treatment goal for Heart Failure (HF) as “preventing the onset of clinical symptoms or reducing symptoms, preventing or reducing hospitalizations, slowing progression of the disease, improving quality of life, and prolonging survival” (Chisolm-Burns, et al., 2019, p. 76). Treatment goals for ACC/AHA stage 3 include symptom control through the addition of ancillary therapies and morbidity reduction.
This patient’s blood pressure is higher than recommended for those with HF. With the hypertension and edema, I would increase the patient’s HCTZ to 25mg daily to start. I would ask the patient to notify the office if her edema was unimproved, then I would increase to 50mg daily. Sinha, (2020), indicates Verapamil should not be used in patients whose hearts do not properly pump blood or those having severe congestive heart failure. I would add an ace inhibitor such as lisinopril or captopril to treat the high blood pressure and heart failure. I would closely monitor the ibuprophen use as Ogbru (2019) indicates nonsteroidal antiinflamatories may increase salt and fluid retention thereby decreasing the effectiveness of the ACE inhibitor Hypertension/Heart Failure Discussion Essays.
Monitoring parameters I would recommend would be blood pressure, maintaining it, according to Chisolm-Burns et al. (2019) at 130/80 or less. I would also monitor the lower extremety edema and suggest the patient weight herself daily and to notify the office should she gain 3 pounds or more from one day to the next. I would also ask the patient to self monitor her activity level and if there are changes in tolerance, SOB with exertion or at rest, or increased SOB affecting sleep.
Non-pharmacological recommendations I would suggest and supported by Chisolm-Burns (2019) would be smoking cessation if the patient is a smoker, salt and fluid restriction, encourage regular exercise, and receipt of flu and pneumonia vaccinations. I would also educate the patient not to use salt substitute because of the potassium and the potential for the ACE inhibitor to increase potassium levels. Also, I would recommend gauging how much this patient can understand and handle at one time and her willingness and readiness for change. It may be that education and non-pharmacological interventions be geared to what is absolutely most important as the patient may only be able to institute one thing at this time Hypertension/Heart Failure Discussion Essays.
References
Chisolm-Burns, M. A., S, Schwinghammer, T. L., Malone, P. M., Kolesar, J. M., Lee, J. M., & Bookstaver, P. B. (2019). Pharmacotherapy Principles & Practice (Fifth ed.). McGrraw-Hill Education.
Ogbru, O. (2019, October 17). ACE inhibitors drug class side effects, list of names, uses, & dosages. Retrieved from MedicineNet: https://www.medicinenet.com/ace_inhibitors/article.htm
Sinha, S. (2020, January 8). Verapamil. Retrieved from Drugs.Com: https://www.drugs.com/verapamil.html
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This patient is a 50 year old African American female with new onset of exertional dyspnea and pedal edema. She has a past medical history of hypertension, she is overweight at 62” and 139 pounds, and she has a reduced ejection fraction of 30%. Based on her reported symptoms I would classify this patient’s heart failure as Stage C since she has new onset of dyspnea and a reduced ejection fraction of 30% (Yancy et al, 2017). This patient’s treatment should begin with measurement of brain natriuretic peptide (BNP) to confirm or rule out a diagnosis of heart failure. If her BNP is positive then treatment should begin with an ACEI or ARB for blood pressure control. This patient is African American and there is a risk of decreased efficacy with ACEI use in African Americans (Medscape.com, 2020) and increased risk of complications like angioedema (Wagner et al, 2015) so I would discontinue her Verapamil and HCTZ and start her on Losartan 25 mg daily, and add spironolactone 12.5 mg daily to reduce her pedal edema with instructions to take during the day if she experiences nocturia. The guidelines point to addition of a beta blocker for this stage of heart failure, so if her blood pressure and renal function can support carvedilol 3.125 twice daily this would also be indicated (Yancy et al, 2017).
Monitoring would include teaching the patient to check her blood pressures daily at the same time and before taking her antihypertensives and to report a systolic pressure less than 120 and a diastolic pressure of less than 60 to her provider; she should also report a heart rate of less than 60 since she will be starting on a beta blocker. In addition to vital sign monitoring, education should include teaching her to identify zones of heart failure management; the green zone indicates no dyspnea and/or edema with normal vital signs, the yellow zone indicates edema up to +2 pitting and some exertional dyspnea and need for notification of symptoms to her provider, and the red zone indicates +3 or greater pitting edema with marked dyspnea and abnormal blood pressure and heart rate which require immediate notification to her health care provider and/or emergency room intervention. Clinical management of this patient would include monitoring of electrolytes, especially potassium as spironolactone is a sparing drug, renal function and BNP to determine efficacy of the regimen and if changes need to be made protect her kidneys. Non-pharmacological measures would be geared towards weight reduction, low or no sodium diet, and physical exercise as tolerated. Most hospitals are paying close attention to heart failure admissions and re-admissions and have instituted heart failure clinics so I would refer this patient to a local heart failure program to help her manage the disease and medications Hypertension/Heart Failure Discussion Essays.
References:
Medscape.com. (2020). ACE inhibitors. https://reference.medscape.com/drugs/ace-inhibitors
Wagner, J., Bench, E., and Plantmason, L. (2015). An unusual case of angiotensin-converting-enzyme-inhibitor related penile angioedema with evolution to the oropharynx. Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health, 16(7), 1185-1187. http://dx.doi.org.wilkes.idm.oclc.org/10.5811/westjem.2015.8.28061
Yancy, C., Jessup, M., Bozkurt, B., Butler, J., Casey, D., Colvin, M., Drazner, M., Filippatos, G., Fonarow, G., Givertz, M., Hollenberg, S., Lindenfeld, J., Masoudi, F., McBride, P., Peterson, P., Stevenson, L., Westlake, C., & Casey, D. Jr. (2017). 2017 ACC/AHA/HFSA focused update of the 2013 AACF/AHA guideline for the management of heart failure: A report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines and The Heart Failure Society of America. Journal of the American College of Cardiology, 70(6), 776-803. http://dx.doi.org.wilkes.idm.oclc.org/10.1016/j.jacc.2017.04.025
A change in this patient’s ability to tolerate ADL’s in the past three months has occurred and requires further investigation. The patient appears to have acute decompensated heart failure (ADHF) and classification of stage “C,” according to the American College of Cardiology Foundation/American Heart Association (ACCF/AHA, 2013). According to recommendations, I would include the following blood work: complete blood count, serum electrolytes, calcium, magnesium, blood urea nitrogen (BUN), serum creatinine, glucose, fasting lipid profile, liver function tests, thyroid-stimulating hormone (TSH), and urinalysis (Kelder et al., 2011). Additionally, I would check for biomarkers, B-type natriuretic peptide (BNP) or N-terminal pro-B-type natriuretic peptide (NT-proBNP) to rule out underlying conditions and further support a heart failure diagnosis (ACCF/AHA, 2017). Although the patient takes a calcium channel blocker and a thiazide diuretic, he remains symptomatic, and blood pressure remains slightly elevated. Blood pressure should be maintained at < 130/80 mmHg. To accomplish this, I would discontinue the verapamil since it can exacerbate heart failure and prescribe an ACE inhibitor such as captopril, 6.25 mg 3 times daily initially, with a maximum dose of 50 mg 3 times daily or an angiotensin receptor blocker (ARB). If this medication does not help achieve the desired response and improvement of symptoms after two weeks, recommendations suggest the addition of a beta-blocker such as bisoprolol 1.25 mg daily (ACCF/AHA, 2013). I would also change the ibuprofen a contraindication in heart failure patients to acetaminophen 325 mg as needed. Non-pharmacological treatment includes the DASH diet and reduced sodium intake, although some newer studies question such diets (Mahtani et al., 2018). Smoking cessation, timely immunizations, and regular supervised exercise (Chisholm-burns et al., 2019). Patient involvement in their care is ideal and should include education about recording daily weight, fluid intake, and exercise tolerance. Also, I would suggest a sleep study to rule out obstructive sleep apnea. Lastly, a referral for cardiac resynchronization therapy (CRT) to explore its possible benefits is an option for the patient (ACCF/AHA, 2013).
References
Chisholm-burns, M. A., Schwinghammer, T. L., Malone, P. M., Kolesar, J. M., Lee, K. C., & Bookstaver, P. B. (2019). In Pharmacotherapy principles and practice, fifth edition (5th ed., pp. 256–257). Mcgraw-hill Education / Medical.
Kelder, J. C., Cramer, M. J., van Wijngaarden, J., van Tooren, R., Mosterd, A., Moons, K. G., Lammers, J. W., Cowie, M. R., Grobbee, D. E., & Hoes, A. W. (2011). The diagnostic value of physical examination and additional testing in primary care patients with suspected heart failure. Circulation, 124(25), 2865–2873. https://doi.org/10.1161/CIRCULATIONAHA.111.019216
Mahtani, K. R., Heneghan, C., Onakpoya, I., Tierney, S., Aronson, J. K., Roberts, N., Hobbs, F., & Nunan, D. (2018). Reduced Salt Intake for Heart Failure: A Systematic Review. JAMA internal medicine, 178(12), 1693–1700. https://doi.org/10.1001/jamainternmed.2018.4673
Yancy, C. W., Jessup, M., Bozkurt, B., Butler, J., Casey, D. E., Jr, Drazner, M. H., Fonarow, G. C., Geraci, S. A., Horwich, T., Januzzi, J. L., Johnson, M. R., Kasper, E. K., Levy, W. C., Masoudi, F. A., McBride, P. E., McMurray, J. J., Mitchell, J. E., Peterson, P. N., Riegel, B., … American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines (2013). 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation, 128(16), e240–e327 Hypertension/Heart Failure Discussion Essays. https://doi.org/10.1161/CIR.0b013e31829e8776
Yancy, C. W., Jessup, M., Bozkurt, B., Butler, J., Casey, D. E., Jr, Colvin, M. M., Drazner, M. H., Filippatos, G. S., Fonarow, G. C., Givertz, M. M., Hollenberg, S. M., Lindenfeld, J., Masoudi, F. A., McBride, P. E., Peterson, P. N., Stevenson, L. W., & Westlake, C. (2017). 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation, 136(6), e137–e161. https://doi.org/10.1161/CIR.0000000000000509
https://docs.google.com/document/d/1LdYMj5I9JRsxUTO8u-8NWehHUTmBk5YHsfhubWtrp4E/edit?usp=sharing
How would you classify her heart failure?
According to the New York Heart Association (NYHA) Classification, the presenting patient would be classified as a class II, which is described as a patient who experiences slight limitation of physical activity, who is comfortable at rest, and ordinary physical activity results in fatigue, palpation, or dyspnea (American Medical Association, 2019). It is indicated that this patient has trouble breathing when she walks 2-3 blocks; class III would be appropriate if the patient experienced marked limitation of physical activity, but without improvement or change in medication regimen, the patient may soon present in class III. The American College of Cardiology Foundation/American Heart Association (ACCF/AHA) staging system complements the NYHA classification. According to the ACCF/AHA, the presenting patient would be a stage C, which pertains to patients with structural heart disease with current or past symptoms of heart failure, such as shortness of breath and reduced exercise tolerance (Dumitru & Baker, 2018).
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What changes (modifications, additions, deletions) to her medications do you recommend that will:
- Improve her symptoms?
According to the 2017 ACCF/AHA Guidelines for the Management of Heart Failure, step 1 of guideline-directed medical therapy (GDMT) for heart failure NYHA class II and III patients includes an ACEi or an ARB for blood pressure management and a beta-blocker, plus diuretics as needed (Yancy et al., 2017). Step 2 of this algorithm includes various suggestions based on certain patient scenarios, however, before moving onto step 2, the patient should have a medication regimen that is optimized by step 1. Verampil, a calcium-channel blocker, should be discontinued and an ACEi or an ARB should be initiated, along with a beta-blocker. Both ACEi’s and ARBs have been shown to decrease HF progression, hospitalizations, and mortality for asymptomatic and symptomatic HF patients, with ARBs being implemented over ACEi for patients who are intolerant to ACEi due to cough or angioedema (Yancy et al., 2017). Additionally, combination therapy with hydralazine and isosorbide dinitrate as add-on therapy to an ACEi or an ARB, or instead of if she cannot tolerate an ACEi or an ARB, would be appropriate for this patient since it is indicated that she is African American and this population is predisposed to having an imbalance of nitric oxide production (Chisholm-burns et al., 2019). After successful toleration of an ACEi or an ARB, ACCF/AHA guidelines indicate that for patients who can tolerate an ACEi or an ARB with chronic, symptomatic heart failure with reduced injection fraction (HFrEF) who are NYHA class II or III, replacement of the ACEi or ARB by an ARNI is recommended to further reduce overall hospitalization, morbidity, and mortality (Yancy et al., 2017). The approved ARNI for a symptomatic HFrEF patient is valsartan/sacuvitril; it should be noted that this medication should not be administered concomitantly with ACEi or within 36 hours of the last ACEi dose (Yancy et al., 2017). The patient should also be prescribed a GDMT beta-blocker such as bisoprolol, carvedilol, or metoprolol succinate (Yancy et al., 2017). According to AACF/AHA guidelines, patients with HFrEF and HTN should have their GDMT titrated to attain SBP <130 mm Hg (Yancy et al, 2017). Substitution of HCTZ for this patient with a loop diuretic, such as furosemide, bumetanide, or torsemide would be beneficial since the patient is experiencing bilateral edema and requires an elevated head of bed when sleeping due to breathing difficulties (Chisholm-burns et al., 2019) . Diuretics are useful for symptom management for relief of congestion and maintaining euvolemia (Chisholm-burns et al., 2019) Hypertension/Heart Failure Discussion Essays.
Impact long term outcomes?
The goal of pharmacologic therapy for this patient is ultimately to improve quality of life and prolong survival by reducing heart failure progression, preventing hospitalization, and reducing symptoms. This can be accomplished through measurable outcomes such as achieving SBP of <130 mm Hg and achieving euvolemia and therefore reducing edema and dyspnea. Increasing EF would also be a desirable outcome of optimized medication therapy.
What monitoring parameters do you recommend?
According to Chisholm-burns et al. (2019), major outcome parameters include monitoring of volume status, exercise tolerance, overall symptoms/ quality of life, adverse drug reactions, and disease progression/ cardiac function. Monitoring of medication adverse effects is important, such as monitoring for cough, angioedema, renal dysfunction, hypotension, and hyperkalemia with ACEi; hyperkalemia, hypotension, and renal dysfunction with ARBs; angioedema, hyperkalemia, hypotension, dizziness, renal dysfunction with sacubitril/ valsartan; bradycardia, heart block, bronchospasm, hypotension, and worsening HF with beta-blockers; and hypovolemia, hypotension, hyponatremia, hypokalemia, hypomagnesemia, hyperuricemia, renal dysfunction, and thirst with diuretics (Chisholm-burns et al., 2019). Additionally, these new medications should be monitored for effectiveness and reduction in symptoms, including fatigue, dyspnea, exercise intolerance, and markers of congestion and fluid volume overload such as edema (Chisholm-burns et al., 2019). Appropriate hemodynamic monitoring and changes in echocardiographic parameters, to determine if EF has increased, should be evaluated approximately 2 months after medication optimization (Chisholm-burns et al., 2019).
Self-monitoring activities of daily living, including ability to perform daily tasks with or without fatigue or dyspnea should be encouraged; a marked reduced ability or exercise intolerance should be reported to the healthcare provider. Additionally, monitoring fluid-volume status can be indicative of fluid retention and can help prevent peripheral or pulmonary symptoms. This can be accomplished through keeping a daily weight log and having the patient weigh themselves first thing in the morning; a weight increase of more than 3 lbs in one day or 5 lbs in one week should be brought to the health provider’s attention (Chisholm-burns et al., 2019).
What non-pharmacologic recommendations do you have?
According to ACCF/ AHA guidelines, dietary sodium should be restricted in heart failure patients to help diminish fluid retention (Yancy et al., 2017). A sodium reduction to a maximum of 2 g/day is generally appropriate and the patient should be counseled on use of sodium substitutes since they can increase the risk of hyperkalemia (Chisholm-burns et al., 2019). When the presenting patient is stable, a cardiac rehabilitation program may be helpful to help the patient with creating an exercise plan that meets her abilities. Mild, low-intensity, aerobic exercise should be encouraged and can include activities such as housework, yard work, walking, swimming, etc., and should not include weight training (Chisholm-burns et al., 2019). Other modifiable risk factors include abstaining from smoking and alcohol use and staying up-to-date with recommended vaccinations such as the annual influenza and pneumococcal vaccines (Chisholm-burns et al., 2019) Hypertension/Heart Failure Discussion Essays.
References
American Medical Association. (2019). New York heart association (NYHA) classification (v2020A) [Specifications Manual for Joint Commision National Quality Measures]. The Joint Commission.
Chisholm-burns, M., Schwinghammer, T., Malone, P., Kolesar, J., Lee, K. C., & Bookstaver, P. B. (2019). Pharmacotherapy principles and practice, fifth edition (5th ed.). Mcgraw-hill Education / Medical.
Dumitru, I., & Baker, M. (2018, May 7). What is the accf/aha staging system for heart failure? MedScape. https://www.medscape.com/answers/163062-86485/what-is-the-accfaha-staging-system-for-heart-failure
Yancy, C. W., Jessup, M., Bozkurt, B., Butler, J., Casey, D. E., Colvin, M. M., Drazner, M. H., Filippatos, G. S., Fonarow, G. C., Givertz, M. M., Hollenberg, S. M., Lindenfeld, J., Masoudi, F. A., McBride, P. E., Peterson, P. N., Stevenson, L., & Westlake, C. (2017). 2017 acc/aha/hfsa focused update of the 2013 accf/aha guideline for the management of heart failure: A report of the American college of cardiology/American heart association task force on clinical practice guidelines and the heart failure society of america. Circulation, 136(6), 776–803. https://doi.org/10.1161/cir.0000000000000509
Heart failure (HF) is a clinical syndrome caused by structural and functional defects in myocardium resulting in impairment of ventricular filling or the ejection of blood Inamdar & Inamdar (2016). The common cause for heart failure is reduced left ventricular myocardial function, pericardium, myocardium, endocardium, heart valves or the great vessels of the heart (aorta, pulmonary artery, inferior vena cava, superior vena cava, pulmonary vein, brachiocephalic artery. Other causes are cardiac overload, ischemic heart condition, structural injuries to the heart, predispositions due to uncontrolled hypertension, diabetes, obesity, renal failure etc. Inamdar et al,. (2016).
Heart failure is classified according to variety of factors: The New York Heart Association classified heart failure into four categories based on the symptoms and efforts required to aggravate them, such as:
- Class 1 patients have no limitation of physical activity
- Class II patients have slight limitation of physical activity
- Class III patients have marked limitation of physical activity
- Class IV patients have symptoms even at rest and are unable to carry on any physical activity without discomfort Ioana (2020).
The other classification was from The American College of Cardiology/American Heart Association (ACC/AHA) heart failure guidelines, heart failure is classified in four:
- Stage A patients are at high risk for heart failure but have no structural heart disease or symptoms of heart failure
- Stage B patients have structural heart disease but have no symptoms of heart failure
- Stage C patients have structural heart disease and have symptoms of heart failure
- Stage D patients have refractory heart failure requiring specialized interventions Ioana (2020).
Heart failure can also be classified according to the left ventricle ejection fraction (EF), and the different between these types are very important in diagnosis and treatments. A normal left ventricular ejection fraction (LVEF) ranges from 55% to 70%. An LVEF of 65%, for example, means that 65% of the total amount of blood in the left ventricle is pumped out with each heartbeat. EF can go up and down, based on one’s heart condition and how well one’s treatment works Cleveland Clinic (n.d.). Ejection fraction (EF) % of 55% to 70% indicates that the heart’s pumping ability is normal and that the patient might have heart failure with preserved ejection fraction HF-pEF).
- Ejection fraction (EF) % of 40% t0 54 %, shows that the heart’s ability to pump blood slightly below normal. There is less blood ejected from the ventricles and such low oxygen to be circulated to the body. Patient may not have symptoms.
- Ejection Fraction (EF)% of 35% to 39%, indicates that the ability of the heart to pump blood is moderately below and the heart failure is mild with reduced EF (HF-rEF).
- Ejection Fraction (EF)% less than 35%, indicates the heart’s pumping ability is moderate-severe HF-rEF Severe increase of life-threatening heartbeats and cardiac irregularities in beating and timing Cleveland Clinic (n.d.).
This patient with EF of 30% per echocardiogram with the above stages of heart failure, it shows that she has severe heart failure with symptoms of orthopnea (sleeps with two pillows), tiredness, shortness of breath walking 2-3 blocks, bilateral edema, creatinine level of 1.1 shows that the renal function has not been affected and as such it is an acute condition and she needs appropriate treatment to halt the progression Hypertension/Heart Failure Discussion Essays.
Patient has evidence of volume overload and is on HCTZ 12.5 daily, thiazides are used at the initial period of heart failure, studies showed that kidneys become less responsive it and it should be changed to loop diuretics such as furosemide and patient’s weight monitored daily. Any weight gain of 2 pounds per day or 5 pounds in one week should be reported cardiologist Hamilton (n.d.). Studies showed that patient with heart failure benefit from Angiotensin-converting enzyme inhibitors (ACEIs) and the therapy reduces left ventricular function ejection fraction of less than 40% Hamilton (n.d.). Patient should benefit changing the verapamil to Lisinopril 20 mg daily to hold if Systolic blood pressure is less than 110mmHg or diastolic blood pressure less than 60 mmHg.
NSAIDs can cause sodium and water retention, as well as reduce formation of the vasodilator prostacyclin in the vessel wall. The risk of increased blood pressure during treatment with NSAIDs has long been known. This side effect seems to be present in all NSAIDs except low dose ASA Varga et al., (2017). As such this patient’s Ibuprofen should be discontinued, and she will benefit from Acetaminophen 650mg twice daily PRN or Tramadol 50 mg twice daily for treatment of arthritis.
Nonpharmacological therapy includes: Exercise such as aerobic activities can help to reverse left ventricular failure and help to reduce symptoms.
Diet: Dietary sodium restriction of 2-3g/day is recommended. Fluid restriction to 2L/day is recommended for patients with evidence of hyponatremia (Na<130 mEq/dL) Ioana (2020).
Daily weight monitoring, weight gain of 2 pounds per day or 5 pounds in one week should be reported cardiologist Hamilton (n.d.).
Reference
Ejection Fraction. (n.d.). Retrieved from https://my.clevelandclinic.org/health/articles/16950-ejection-fraction
Inamdar, A. A., & Inamdar, A. C. (2016). Heart Failure: Diagnosis, Management and Utilization. Journal of clinical medicine, 5(7), 62. https://doi.org/10.3390/jcm5070062
Ioana Dumitru, M. (2020, July 24). Heart Failure.
https://emedicine.medscape.com/article/163062-overview#a2
Robert Hamilton CHF Update and the Pharmacists Role. (n.d.) https://www.medscape.org/viewarticle/418375
Varga, Z., Sabzwari, S., & Vargova, V. (2017). Cardiovascular Risk of Nonsteroidal Anti- Inflammatory Drugs: An Under-Recognized Public Health Issue. Cureus, 9(4), e1144. https://doi.org/10.7759/cureus.1144
Module X: Hypertension/Heart Failure Discussion
Congestive heart failure is a severe progressive condition that affects the pumping power of the heart muscles. Because of decreased cardiac output the organs get inadequate blood, oxygen, and nutrients. CHF usually affects the lungs, heart, and kidneys(“Biomarkers in Heart Failure,” 2020). A decreased output causes kidney to retain water and salt. Because of the increased water retention, other organs get congested, leading to increase pressure on the heart. Causes of heart failure include Coronary artery disease, hypertension, alcohol abuse, valve disorders, and thyroid abnormalities.
In our case study our 50-year-old female arrives to the clinic to follow up on her heart failure. According to the NYHA class rating of heart failure our case study patient is in Class 2, and according to ACC/AHA stages she is in stage C heart failure. I am classifying her in this stage or class due to shortness of breath, fatigue, less ability to exercise, EF 30% so showing signs of heart failure damage.
In a review of her current medication regime, I would continue the hydrochlorothiazide, but I would increase her dose to 25 mg daily to increase its effect both as a diuretic and fore its effect on assisting in lowering the blood pressure. I would closely monitor this patient for hypokalemia and add a potassium supplement if needed. I would discontinue this patient’s verapamil SA 120 mg, a calcium channel blocker. Calcium channel blockers should be used in caution with those in heart failure as they can cause edema and decrease the hearts ability to pump blood(Heidenreich, 2016). I would choose to start this patient on an ACE inhibitor such as Lisinopril 5mg as a starting dose with the increased diuretic. Ace inhibitors are critical in the treatment of heart failure, they dilate the blood vessels to improve blood flow through the heart(“Ace Inhibitors,” 2018). Ace inhibitors also help block angiotensin, a substance in the blood that narrows vessels in the body. If this patient is not controlled with ACE inhibitors and diuretics, I would next ad a beta-blocker such as metoprolol. Beta blockers reduce mortality in chronic heart failure when used in conjunction with diuretics and ACE inhibitors. Ace inhibitors will decrease the work of the heart helping this patient to breath better and have more energy. The diuretic will help remove the extra fluid she retains and also take less stress off the heart, and decrease edema. With the new medications today, heart failure patients can live a long productive life, prolonging further heart damage. I would discontinue this patient Ibuprofen as NSAIDS have an increased risk of heart failure and can cause the body to retain more salt and water. I would recommend this patient non-pharmacological treatment for knee pain such as Ice, heat, and rest. This patient could try a topical arthritis medication such as Capzasin or solonpas. If she still needs relief through oral medication then I would suggest acetaminophen 1000mg every 6-8 hours. I would recommend this patient also make some life style modifications her BMI is on the overweight category, so recommending a low fat, low salt diet to improve health and promote weight loss would be beneficial to her health. As the medications start to work and this patient feels better, increasing exercise for weight loss and heart health is beneficial. If this patient is a smoker then I would council her on the benefit of smoking cessation on her health, this patient should avoid alcohol and licorice Hypertension/Heart Failure Discussion Essays. Licorice has been found to prompt potassium levels in the body to decline, which may lead to issues such as abnormal heart rate, high blood pressure, edema, and lethargy(Heidenreich, 2016).
Heart failure can now be treated successfully and offer patients a longer, higher quality life. Monitoring this patient for effectiveness of medications is important, as dosages can be increased and other medications added. This patient needs good cardiac rehab programs that support education and medication compliance. Good medical examinations including heart sounds, lung sounds, checking for increased edema, lab review and medication adjustments will be needed for the rest of this patient’s life. A referral to a cardiologist would also be recommended to help offer guidance when this patient’s heart failure progresses.
References
Ace inhibitors. (2018). Reactions Weekly, 1708(1), 14–15. https://doi.org/10.1007/s40278-018-48107-3
Biomarkers in heart failure. (2020). In Heart failure (pp. 276–289). CRC Press. https://doi.org/10.1201/b13888-17
Heidenreich, P. (2016). Heart failure patients need more than heart failure care ∗. JACC: Heart Failure, 4(3), 194–196. https://doi.org/10.1016/j.jchf.2016.01.006
Here are some additional questions that you should consider for this weeks discussion:
What are some of both the short-term and long-term benefits seen with prescribing ACEI’s for heart failure?
What are some side effects of ACEI’s? What can you switch to if your patient cannot tolerate an ACEI?
If your patient had chronic kidney disease in addition to HTN and HF, what would his blood pressure goal be? Hypertension/Heart Failure Discussion Essays
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Heart failure prevents the heart from supplying enough carbon monoxide for metabolic operations (Chisholm-Burns et al., 2016). The patient’s heart failure is classifiable as class III and stage C. Her symptoms are visible and cause her difficulties in engaging in everyday activities like walking across blocks. She reports having been tired for about three months and having breathing challenges. Her situation only improves when she is at rest. Alternatively, she has to rely on two pillows for more comfort when sleeping. Her echocardiogram readings prove that the symptoms are due to an increase in the probability of systolic left ventricular failure.
Her symptoms are improving through continuing the use of her Beta-blocker medication because her EF is less than 40%. In worst situations, the doctor should offer an alternative prescription to Verapamil due to its contraindications, especially when the heart failure becomes congestive (Stams et al., 2012). Verapamil is a calcium channel blocker, thus lessens the heart’s functionality. Otherwise, the HCTZ is a correct prescription for her high blood pressure that could trigger heart failure if it persists. Additionally, they can take diuretics and hydralazine or an aldosterone antagonist in case the ACE/ARB/ARNI are inefficient. These considerations would improve her symptoms. Alternatively, the long-term solution involves surgery to avert the long term impact of heart failure Hypertension/Heart Failure Discussion Essays.
The physicians should also consider monitoring parameters such as the regular assessments of one’s chest, arterial pressure, and the jugular venous pressure to avoid uncontrolled hypertension (Nicholls & Richards, 2007). Additionally, the patient’s body weight should also be examined to monitor factors such as an increase in their sodium intake and variances in their heart rate to prevent situations such as over diuresis. These monitoring techniques are manageable through approaches like telemonitoring at the patient’s home. Non-pharmacologically, the patient should exercise regularly or simple walking despite feeling tired. She should also focus on a low sodium and cholesterol diet such as the DASH diet. Seemingly, her situation will become better. Any medical decisions must depend on the patient’s condition, the drug’s side effects, and a proper follow-up plan.
References
Chisholm-Burns, M. A., Wells, B. G., & Schwinghammer, T. L. (2016). Pharmacotherapy principles and practice. McGraw-Hill.
Nicholls, M. G., & Richards, A. M. (2007). Disease monitoring of patients with chronic heart failure. Heart, 93(4), 519-523.
Stams, T. R., Bourgonje, V. J., Vos, M. A., & van der Heyden, M. A. (2012). Verapamil as an antiarrhythmic agent in congestive heart failure: hopping from rabbit to human?. British journal of pharmacology, 166(2), 554-556 Hypertension/Heart Failure Discussion Essays.
In this scenario, a 50-year-old African American woman presents with lethargy for the last three months, trouble breathing at night and on exertion, arthritis, and edema in both feet. I would classify her with heart failure NYHA Functional Class II ACC/AHA stage C related to her signs and symptoms. CHF’s classic signs and symptoms are shortness of breath on exertion, trouble breathing at night, edema, and an EF of 30% (Chisholm-Burns et al., 2019). EF percentages 40% and below indicate heart failure (Chisholm-Burns et al., 2019). I would first start by providing a full assessment of the patient concentrating on heart sounds, lung sounds, and edema evaluation. I would then review the medications. I would add furosemide 40mg daily to her current regimen to reduce her edema by increasing sodium and water excretion, so it is essential to monitor sodium levels when starting a furosemide patient (Chisholm-Burns et al., 2019). I would recommend the re-evaluation of medication in one week with labs. Depending on her blood pressure, I would recommend an ACE inhibitor and a beta-blocker and d/c the verapamil to increase blood pressure control. (Chisholm-Burns et al., 2019). I recommend daily weights, pulse, and blood pressure. If the patient experiences any weight gain over two pounds, she needs to contact her Provider immediately (Chisholm-Burns et al., 2019). Education for this patient would also include explaining that her chronic hypertension is why she now has HF (Hajar, 2019). As a provider, it is vital to explain why she must take her medication and monitor her weight.
In addition to medication changes, I would provide education on a reduced-sodium diet and encourage a daily exercise program. I would also explain the importance of managing heart failure to prevent future damage to the heart and other organs. HF is very serious and is irreversible. It is a worldwide pandemic that affects 26 million people (Dokainish et al., 2017). HF is associated with high mortality and a large portion of all healthcare costs (Dokainish et al., 2017). HF and CHF patients are more likely to develop COPD, causing even more complications related to medication regiments and disease management (Canepa et al., 2017). When assessing HF patients for the first time, it is essential to evaluate comorbidities such as COPD (Canepa et al., 2017) Hypertension/Heart Failure Discussion Essays.
Canepa, M., Straburzynska-Migaj, E., Drozdz, J., Fernandez-Vivancos, C., Pinilla, J. M. G., Nyolczas, N., … Tavazzi, L. (2017). Characteristics, treatments and 1-year prognosis of hospitalized and ambulatory heart failure patients with chronic obstructive pulmonary disease in the European Society of Cardiology Heart Failure Long-Term Registry. European Journal of Heart Failure, 20(1), 100–110. https://doi.org/10.1002/ejhf.964
Chisholm-Burns, M. A., Kolesar, J. M., Lee, K. C., Malone, P. M., Schwinghammer, T. L., & Bookstaver, P. B. (2019). Pharmacotherapy principles & practice. McGraw-Hill Education.
Dokainish, H., Teo, K., Zhu, J., Roy, A., Alhabib, K. F., Elsayed, A., … Mondo, C. (2017). Global mortality variations in patients with heart failure: results from the International Congestive Heart Failure (INTER-CHF) prospective cohort study. The Lancet Global Health, 5(7). https://doi.org/10.1016/s2214-109x(17)30196-1
Hajar, R. (2019). Congestive heart failure: A history. Heart Views, 20(3), 129–130. https://doi.org/10.4103/heartviews.heartviews_77_19
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How would you classify her heart failure?
Our young lady is feeling tired and is experiencing shortness of breath while walking short distances. New York Heart Association would classify her as II and the American College of Cardiology/American heart Association would stage her at C due to cardiac disease that results in slight limitations of physical activity that results in fatigue and dyspnea.(Chisholm-burns et al., 2019)
What changes (modifications, additions, deletions) to her medications do you recommend?
According to 2017 ACC/AHA/HFSA guidelines I would discontinue her verapamil and HCTZ and start her on a loop diuretic such as Furosemide 20 mg BID to control her edema and fluid overload and begin an ACE inhibitor such as Captopril 6.25 mg TID and titrate up as needed. (Heart Failure – American College of Cardiology, 2017) I may also consider adding a beta blocker due to her advanced stage of C. Once she maxes her dose of beta blockers, Ivabradine could be considered due to her EF of 30%, SR, and HR greater than 70. (Hajuli & Ludhwami, 2020)
I would also discontinue her NSAIDS due to the history of worsening CHF and kidney function. (Hajuli & Ludhwami, 2020) If after 3 months on her new therapy there is no improvement of her EF of 30% I would discuss the need for an ICD device. (Hajuli & Ludhwami, 2020) Hypertension/Heart Failure Discussion Essays
What monitoring parameters do you recommend?
I would monitor her blood pressure, electrolytes, BUN and creatine for the ACE addition, her BP, HR, and ECG for the Beta blocker addition, and weight and kidney function witht he loop diuretic addition. (Chisholm-burns et al., 2019) Follow up of her ejection fraction in 3 months to see improvement with the new medicine regime would also be needed.
What positive outcomes would you expect as a result of your recommendations?
Hopefully with the proper medicine her EF would improve above 35%, her edema would be gone, and her symptoms with walking would be gone.
What non-pharmocologic recommendations do you have?
I would recommend a diet with sodium restriction of 2-3 grams per day, fluid restriction of 2 litres per day, daily weights, patient education on signs and symptoms and an aerobic exercise program. (Hajuli & Ludhwami, 2020)
References
Chisholm-burns, M. A., Schwinghammer, T. L., Malone, P. M., Kolesar, J. M., Lee, K. C., & Bookstaver, P. B. (2019). In Pharmacotherapy principles and practice, fifth edition (5th ed., p. 80). Mcgraw-hill Education / Medical.
Hajuli, S., & Ludhwami, D. (2020). Heart failure and ejection fraction – statpearls – ncbi bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK553115/
Heart failure – american college of cardiology. (2017). American College of Cardiology. https://www.acc.org/education-and-meetings/products-and-resources/guideline-education/heart-failure Hypertension/Heart Failure Discussion Essays.