Case study report

1. By: Dale Faith O. Dumalagan
Marc Edrial

2.  is a clinical syndrome caused by the inability of the
heart to pump sufficient blood to meet the
metabolic needs of the body.
 it can result from any disorder that reduces
ventricular filling (diastolic dysfunction) and/or
myocardial contractility (systolic dysfunction)
 the leading cause of HF are coronary artery
disease and HTN

5. • DECREASED CONTRACTILITY- The strength for
ventricular contraction is attenuated and inadequate for
creating adequate stroke volume, resulting to inadequate
cardiac output.

6. Can be caused by:
• Ischemic Heart Disease (Coronary Atherosclerosis)
• Hypertension
• Dilated Cardiomyopathy

7. IHF to Systolic dysfunction
• IHF is plaque build-up
• Less oxygenated blood to
cardiac muscles
= Weaker cardiac muscles
=Weaker contractions!

8. HTN to Systolic Dysfunction
• Increase pressure means
heart needs to pump harder
• It causes Hypertrophy or more
cardiac muscle
• More cardiac muscle = More
oxygen
• Cardiac walls are thicker =
less blood = WEAKER
CONTRACTIONS (Systolic
dysfunction!)

9. Dilated Cardiomyopathy to Systolic Dysfunction
• Heart chamber grows big
= less muscle (Thinner
cardiac muscles) causing
less pumping out of blood
=Heart failure!

10. …It leads to Pulmonary Edema!
• Due to excess fluid in the lungs
• Causing difficult to exchange CO2 & O2
• LESS O2 = Less supply to muscles
• Symptoms may include
– Dyspnea
– Orthopnea
– Rales/ Crackles

11. So basically,
• Less cardiac output means less oxygenated blood
supplied
• Less oxygenated blood supple means no oxygen supply
on muscles esp. cardiac muscles
• No oxygen means cardiac muscle cell death
• Cardiac muscle cell death = less contractions
• And so on 

12. Drugs needed 
• Ace inhibitors to dilate
blood vessels
• Diuretics to reduce fluid
retention

14. Ejection Fraction
- is a measurement of the
percentage of blood leaving
your heart each time it
contracts.
- normal values are 50-75%
• Formula
SV= EDV - ESV
EF= SV / EDV

15. Causes of Diastolic Dysfunction:
 Increased ventricular stiffness
 Ventricular hypertrophy
 Infiltrative myocardial disease
 Myocardial ischemia and infarction
 Mitral or tricuspid valve stenosis
 Pericardial disease
• Pericarditis
• Pericardial tamponade

18. PATIENT INFORMATION
• Name: Richard Anderson
• Age: 65
• Mr. Anderson is a retired
musician who lives alone.
Prior to his strokes, his
hobby was repairing and
playing antique pump
organs.

19. CHIEF COMPLAINT
“I think I might have the flu. I have been feeling
run down, and I haven’t been able to get up the
stairs to my bedroom because I get winded.”

20. HISTORY OF PAST ILLNESSES
• Short of breath and diaphoretic after attempting to climb
a flight of stairs. When evaluated by the paramedics in
his home, the diaphoresis had resolved, and his heart
rate was in the range of 100–120 bpm.
• Progressively worsening dyspnea on exertion over the
last 5 days.

21. HISTORY OF PAST ILLNESSES
• His shortness of breath is often worse at night, forcing
him to “sit bolt upright.” He began sleeping in his recliner
about 3 days ago.
• He is unable to complete physical activities that he could
do 2 weeks ago without difficulty.

22. PAST MEDICAL HISTORY
• Type 2 DM × 15 years, untreated until 3 years ago;
• Neuropathy × 2 years
• Retinopathy × 1 year
• HTN × 20 years
• Hypercholesterolemia (documented 6 months ago)
• CVA × 2 (2 and 3 years ago)
• Recurrent TIAs × 1 year

23. FAMILY HISTORY
• FATHER- died at age 65 of a Heart Attack
• MOTHER- died in her 70's in a motor vehicular accident
• BROTHER- + DM
• PATIENT
• +DM
• +HTN

24. SOCIAL HISTORY
• He has a 30 pack-year
history of smoking but
reports quitting 22 years
ago.
• He has positive history for
alcohol use but states he
“hasn’t had a drop in 12
years.”

25. MEDICATIONS
• Rosiglitazone 4 mg po once daily
• Metformin XR 1,000 mg po once daily
• Glyburide 5 mg po BID
• Atorvastatin 20 mg po once daily (LDL 90 mg/dL 1
month ago)
• Lisinopril 10 mg po once daily
• Aspirin/extended-release dipyridamole 25 mg/200 mg
po twice daily
• NKDA

26. REVIEW OF SYSTEMS
• Reports of having headaches recently
• No chest pain
• No chonic cough
• Complains recent abdominal bloating
• Awakened the past four evenings to relieve his bladder
• Weakness in right lower extremity
• No chronic joint pain

27. PHYSICAL EXAMINATION
• Gen
The patient is sitting up on the gurney in the ED in
moderate distress.
• VS
BP 150/95
P 100–120
RR 22
T 35°C
Wt 103 kg (usual weight 93 kg)
Ht 5'11''

28. PHYSICAL EXAMINATION
• HEENT
PERRLA, EOMI, fundi were not examined. He has a
complete upper denture and about two-thirds of the teeth in
the lower jaw are remaining and are in fair repair.
• Neck
(+) JVD at 30° (8 cm). Carotid bruit is not appreciated.
Nolymphadenopathy or thyromegaly.
• Lungs/Thorax
Respirations are even. There are fine crackles in both lung
fields

29. PHYSICAL EXAMINATION
• Skin
Pale and diaphoretic, no unusual lesions
• Heart
Regular rhythm, no rubs, variation in intensity of S1 as
expected. S3 is appreciated at apex in lateral position. PMI
displaced laterally and difficult to discern.
• Abd
Soft, NT/ND, (+) HJR, liver and spleen slightly enlarged, no
masses, hypoactive bowel sounds

30. PHYSICAL EXAMINATION
• Genit/Rect
Guaiac (–), genital examination not performed
• Ext
3+ pitting pedal edema bilaterally; radial and pedal pulses
are of poor intensity bilaterally; grip strength greater on left
than on right
• Neuro
A & O × 3, CNs intact. Some sensory loss in both LE below
the knee. DTR 1+

31. PHYSICAL EXAMINATION
• ECG
Sinus tachycardia rate of 112, QRS 0.08. Diffuse non
specific ST-T wave changes. Low voltage.
• Chest X-Ray
PA and lateral show evidence of congestive failure with
cardiomegaly, interstitial edema, and some early alveolar
edema. There is a small right pleural effusion.

32. • Note presence of
severe Left
Ventricular Dilation

33. • Note presence of
Pulmonary effusion,
edema

34. LABORATORY
Lab Results Normal Values
Na = 139 mEq/L 135 – 145 mEq/L
K = 4.3 mEq/L 3.5 – 5.0 mEq/L
Cl = 99 mEq/L 97 – 107 mEq/L
CO2 = 27 mEq/L 23 - 29 mEq/L
BUN = 20 mg/dL 6 - 20mg/dL
SCr = 1.8 mg/dL 0.7 – 1.3 mg/dL
Glucose = 139 mg/dL
Normal glucose level
< 100 mg/dL after not eating for at
least 8 hours
Less than 140 mg/dL
Two hours after eating
Remarks
Normal
Normal
Normal
Normal
Normal
High
Normal

35. LABORATORY
Lab Results Remarks Normal Values
Ca = 8.8 mg/dL Normal 8.5 – 10.2 mg/dL
Mg = 1.2 mEq/dL Low 1.5 – 2.5 mEq/dL
Hgb = 12.6 g/dL Low 13.5 – 17 g/dL
Hct = 39.5% Normal 38.8 – 50 %
WBC = 8.6 x 103/mm3 Normal 5.0 – 10.0 x 103/mm3
Plts = 339 x 103/mm3 Normal 150 – 400 x 103/mm3

36. LABORATORY
Lab Results Remarks Normal Values
BNP = 1,200 pg/mL High
< 50 years – 300-450 pg/mL
50-75 years – 300-900 pg/mL
>75 years – 300-1800 pg/mL
Troponin = 1.8 ng/ml High 0.01 ng/mL
Alk phos = 150 IU/L High 44 to 147 IU/L
AST = 36 IU/L Normal 10 to 40 units/L
ALT = 43 IU/L Normal 7 to 56 units per liter
GGT 37 IU/L Normal 0-45 U/L
T bili = 0.2 mg/dL Low 0.3 to 1.9 mg/dL
INR = 2.8 High 1.1 or below
PT = 20.6 sec High 11 to 13.5
AIC = 6.9% High below 5.7 percent

37. ASSESMENT
• Diabetic patient with new-onset congestive
heart failure

38. Problems
• 1a. Create a list of the patient's drug-related
problems
–Aspirin and Lisinopril. NSAIDS and ACE Inhibitors
must not be taken together as it may cause less
hypotensive effects and might cause injury if not taken
with strict and high precaution.

39. Problems
• 1b. What signs, symptoms, and other information
indicate the presence and severity of the patient's
heart failure?
–Frequent TIA's for the past year, SOB and
Diaphoresis upon climbing stairs, worsening
Dyspnea, and began to opt sleeping in his recliner 3
days PTA

40. Problems
• 1c. What is the classification and staging of heart
failure for this patient upon presentation?
Stage C, cardiac dysfunction is present, as are
symptoms. Tiredness while performing simple
activities like walking are common symptoms.
Shortness of breath and overall fatigue are present.

42. Problems
• 1d. Could any of this patient's problems have been
caused by drug therapy?
–Possibly because of the drug interaction between
Aspirin and Lisinopril.

43. Problems
• 2a. What are the goals for the pharmacologic
management of heart failure in this patient?
– Lower blood pressure
– Lower BNP Levels
– Adequate glucose levels
– Control to hypercholesterolemia
The therapeutic goals for CHF are to improve quality of
life, relieve or reduce symptoms, prevent or minimize
hospitalizations, slow disease progression, and prolong
survival.

44. Problems
• 2b. Considering his other medical problems, what
other treatment goals should be established?
– Consult a Ophthalmologist for Retinopathy
– Consult a Neurologist for Neuropathy
– Control of diet due to DM and Hypercholesterolemia
– Exercise appropriate for his condition

45. Problems
• 3. What medications are indicated in the long-term
management of this patient's heart failure based
upon his stage of heart failure?
• ACE Inhibitor
• Beta Blocker
• Loop Diuretic
• Spironolactone
• Digoxin

46. Problems
• 4. What drugs, doses, schedules, and duration are
best suited for the management of this patient?
• ACE Inhibitor- Lisinopril 20mg once daily, at 9am
• Beta Blocker- Carvedilol 6.25mg twice daily, at 9am and at
5pm
• Loop Diuretic- Furosemide 40mg once daily, at 9am
• Spironolactone- 12.5mg once daily, at 9am
• Digoxin- 0.125mg once daily, at 9am

47. Problems
• 5. What clinical and laboratory parameters are
needed to evaluate the therapy for achievement of
the desired therapeutic outcome and to detect and
prevent adverse events?
• The patient may undergo monitoring of BNP levels, also
close observation with regards to the side effects dure to
added medications like beta blockers.

48. BNP levels
• When cardiac muscle stretches, BNP is released to the
system
• In Systolic dysfunction where there is less contractility,
cardiac muscles are stretched
• More stretched = MORE BNP

49. • Over the next 3 days, the patient received maximal drug
therapy, and his condition improved. He underwent a
cardiac catheterization and bare metal stent placement for
a 90% LAD lesion. He was discharged on lisinopril 20 mg
po daily, carvedilol 6.25 mg po BID, furosemide 40 mg po
daily, potassium chloride 40 mEq po daily, magnesium
oxide 400 mg po daily, insulin glargine 20 units SC hs,
aspart insulin 5 units SC AC, clopidogrel 75 mg po daily,
aspirin 325 mg po daily, and atorvastatin 40 mg po daily.

50. Problems
• 6. What information should be provided to the
patient about the medications used to treat his
heart failure?
• ACE Inhibitors (Lisinopril 20mg)- The most important agent
in CHF, They also raise blood flow, which helps to lower
your heart's workload.
• Beta Blockers (Carvedilol 6.25 BID)- Reduces
hypertension
• Loop Diuretic (Furosemide 40mg)- treats hypertension and
edema due to CHF

51. • Potassium chloride (40 mEq) – Prevention of HTN
• Mg oxide (400 mg) – for cardiac arrythmia
• Insulin glargine (40 units SC) - For Diabetes
• Aspart Insulin (5 units AC) - For Diabetes
• Clopidogrel (5 mg) - Prevention of a Heart Attack via non-
coagulation of platelets
• Aspirin (325 mg) - In combination with Clopidogrel, for
thinning blood and keep it flowing
• Atorvastatin (40 mg) - For hypercholesterolemia

52. Follow-up questions
• 1. What is the role of routine monitoring of BNP
levels in the management of this patients heart
failure?
• BNP or B-type Natriuretic Peptide is a hormone created by
the heart. High levels of BNP indicates heart failure and
therefore routinely monitoring BNP may aid in determining
the current status of the patient.

53. Follow-up questions
• 2. The patient's development of worsening symptoms may
be a result of carvedilol therapy. Outline information that
should be provided to the patient about common adverse
effects when initiating or titrating carvedilol therapy.
Describe how they should be managed if they occur.
Sir, this medication may possibly have unwanted effects within the
first three months of medication before its benefits are achieved.
You may experience your dyspnea worsened, low blood pressure,
and even fatigue. Should you opt to lessen them due to discomfort,
you may consult your physician for dose adjustments, or
prescription of a different drug.

54. Follow-up questions
• 3. Outline a therapeutic plan for transitioning this
patient from carvedilol immediate release to the
controlled release product
• Carvedilol
Start at 3.125 mg bid
Slowly titrate to 12.5 - 25 mg bid over 2 weeks
This should control the possible inconveniece of side effects
before its benefits to be achieved.

55. Heart Failure:
Diastolic Dysfunction
By: Dale Faith O. Dumalagan
Be Still My Racing Heart.............................. Level III
Jon D. Horton, PharmD

56. Patient Profile
Name: Nina Orendorff
Age: 83 years old
Sex: Female

57. Chief Complaint
“I can't catch my breath”

58. History of Present Illness
 Patient presented general complaints, feeling run down
and unable to breathe
 Heart Rate : 110-120 beats per minute
 “ I had progressively worsening dyspnea on exertion over
the last 2 weeks ”
 Her shortness of breath has severely limited her activities
and has increased to persist even at rest

59. Past Medical History
 Type 2 DM x 5 years, diet controlled
 HTN x 40 years

60. Family History
 Father died at age of 85 y/old
 Mother died at 88 y/old after a hip fracture
 One brother (80 y/old) alive with no significant history

61. Social History
 Retired schoolteacher who lives at
home alone
 Reports enjoying a cocktail while
playing cards with friends

62. Current Medical Treatment
MEDICATION DOSE
Minoxidil 10 mg po bid
Minoxidil
Is an antihypertensive peripheral vasodilator medication.
It also slows hair loss and promotes hair regrowth in some people.
is used with other medications to treat high blood
pressure (hypertension). Lowering high blood pressure helps
prevent strokes, heart attacks, and kidney problems.
Minoxidil works by relaxing blood vessels so blood can flow more
easily.

63. Allergy
 No known drug allergy

64. Review of Systems
General
 Reports recent weight gain
 General reduction in her state of health related to an inability
to get around as she usually has in the past.
Cardiovascular
 No chest pain
 Reports dyspnea on exertion, orthopnea and paroxysmal
nocturnal dyspnea
 Noted peripheral edema

65. Resp
 Shortness of breath
 New cough but not productive
 No recent respiratory
infections
GI
 No recent changes in bowel
habits
GU
 No complaints
MS
 No MS pain or
weakness
 General inability to
exercise secondary to
becoming “winded”
Neuro
 No abnormalities noted

66. Physical Examination
General
Patient is sitting up on the gurney in moderate distress
Vital Signs
BP : 150/100 120/80
P : 100 - 130 (regular)
RR : 28 fast
Temp: 35℃
Wt : 73 kg (usual 65 kg)
Ht : 5'3”

67. Skin
 Color : Pale
 No unusual lesions noted
HEENT
 PERRLA, EOMI, fundi were examined
 Complete dentition, teeth fair pair
Neck
(+) JVD at 30° (6 cm) (4 cm or less)
 Carotid bruits not appreciated
 No lymphadenopathy or thyromegaly

68. Lungs / Thorax
 Respirations are even
 Crackles in both lung fields posteriorly noted one-third of the
way up the lung fields
 No CVAT
Heart
 Regular rhythm
 No rubs
 Variation in intensity of S1 as expected
 S3 appreciated at the apex in the lateral position
 PMI displaced laterally and difficult to discern

69. ABD
 Soft, NT/ND
 (+) HJR
 Liver and spleen slightly enlarged
 No masses
 Hypoactive bowel sounds
Genit / Rect
(-) guaiac
Genital examination ( Not performed)
MS / Ext
 2+ pitting pedal edema
bilaterally (moderate)
 Radial and pedal pulse are of
poor intensity bilaterally
 Grip strength even
Neuro
 A & O x 3
 CNs intact
 DTR intact

70. Laboratory Findings
RESULTS NORMAL VALUES INTERPRETATION
SODIUM 144 mEq/L 135 – 145 mEq/L Normal
Potassium 4.4 mEq/L 3.5 – 5.0 mEq/L Normal
Chloride 101 mEq/L 97 – 107 mEq/L Normal
Carbon dioxide 27 mEq/L 23 - 29 mEq/L Normal
BUN 12 mg/dL 8 - 20mg/dL Normal
SCr 1.4 mg/dL 0.7 – 1.55 mg/dL Normal
Glucose 148mg/dL Normal glucose level
< 100 mg/dL after not eating for at least 8
hours
Less than 140 mg/dL
Two hours after eating
High
BNP 1,100 pg/mL < 50 years – 300-450 pg/mL
50-75 years – 300-900 pg/mL
>75 years – 300-1800 pg/mL
Normal

71. RESULTS NORMAL VALUES INTERPRETATION
HgB 11.6 g/dL 13.5 – 17 g/dL Low
Hct 38.5% 38.8 – 50 % Normal
Plt 239 x 103/mm3 150 – 400 x 103/mm3 Normal
WBC 6.6 x 103/mm3 5.0 – 10.0 x 103/mm3 Normal
PMNs 40% 35-46% Normal
Lymphs 13% 20-40% Low
Monos 7% 2-8% Normal
Troponin I 1.1 ng/dL Quantitative: 0.1-2
ng/dL
Normal

72. RESULTS NORMAL VALUES INTERPRETATION
Mg 1.8 mEq/dL 1.5 – 2.5 mEq/dL Normal
Ca 9.1 mg/dL 8.5 – 10.8 mg/dL Normal
AST 41 IU/L 0-35 units/L Low
ALT 27 IU/L 0-35 units/L Low means normal
Alk phos 80 IU/L 44 to 147 IU/L High
GGT 24 IU/L 0-30 U/L. Normal
T. bili 0.3 mg/dL 0.3-1.3 mg/dL Normal

73. RESULTS NORMAL VALUES INTERPRETATION
CK 20 IU/L 35-150 IU/L Low
CK-MB 0.8 IU/L 5-25 IU/L. Low
PT 12.6 sec 10-13 sec Normal
INR 1.1 1.1 or below Normal
TSH 1.12 mIU/L 0.3 - 5.0 mIU/L Normal
AIC 6.7% below 5.7% High

74. Electrocardiogram
 Sinus tachycardia rate of 112 60–100 bpm
 QRS 0.08
 Diffuse nonspecific ST-T wave changes
 Low voltage

75. CXR
PA and lateral views show evidence of interstitial edema and
some early alveolar edema

76. Assessment
Diet-controlled patient with Type 2 DM and new-onset
congestive heart failure

77. Clinical Course
The patient was admitted to a telemetry unit. A 2D
echocardiogram was obtained to evaluate LV and
valvular function. Results revealed evidence of
impaired ventricular relaxation and elevated left
ventricular atrial filling pressures consistent with
grade II diastolic dysfunction.
EF was estimated at 45-50%, there was no
evidence of mitral stenosis or pericardial disease
Clinical Course

78. 1.a) Create a list of this patient's drug-related
problems.
Question: Problem Identification
DRUG USE PROBLEM MANAGEMENT
Minoxidil
10 mg po bid
• Tx of HTN that is
symptomatic or
associated with target
organ damage and is not
manageable with
maximum therapeutic
doses of a diuretic plus
two other
antihypertensive drugs.
• reduced supine diastolic
blood pressure by 20
mm Hg or to 90 mm Hg
or less in approximately
75% of patients
1. No interaction because there
hasn't been any other medication
2. Patient has Stage II hypertension
3. Cardiovascular side effects are
related to peripheral vasodilation
and sodium and water retention,
and include hypotension, sinus
tachycardia, provocation of angina,
edema, and weight gain. Edema is
expected without concomitant use
of a diuretic agent.
1. Add another drugs: Diuretics,
ACE Inhibitors, B-blockers,
ARBs, Aldosterone
Antagonists, Digoxin, Nitrates
and Hydralazides
2. ACE inhibitor & ARBs
3. Concomitant use of an
adequate diuretic is required;
high ceiling (loop) diuretic is
almost always required;
Monitor fluid and
electrolyte balance and body
weight

79. DRUG USE PROBLEM MANAGEMENT
Minoxidil
10 mg po bid
4. Angina may worsen or appear
for the first time during minoxidil
treatment
5. Pulmonary edema
4. Conduct ECG and monitor
5. Diuretic treatment alone, or in
combination with restricted salt
intake, will usually minimize fluid
retention

80. 1.b) What signs, symptoms, and other information indicate
the presence and severity of the patient's heart failure?
1. Elevated HR - 110-120bpm
2. Worse dyspnea on exertion over two weeks, orthopenia , & paroxysmal nocturnal dyspnea
3. SOB, persist even at rest
4. Type II DM
5. HTN x40yrs
6. Only one medication, Minoxidil (not enough)
7. Weight gain
8. Peripheral edema
9. Elevated BP 150/100
10. Fast Respiratory Rate
11. (+) JVD at 30°(6cm) Normal: 4cm or less
12. Lungs: Crackles on both lungs but no cough is not productive
13. Heart: S3 appreciated at apex in lateral position, PMI displaced laterally & difficult to discern
14. ABD: (+) HJR, Liver and spleen slightly enlarged
15. Detection of Troponin I ( slight elevation)

81. 1.c) What are the
classification and staging of
this patient's heart failure
upon presentation?
Stage C

82. Stage A
 Identify and modify risk factors to prevent development of
structural heart disease and subsequent HF. Strategies include
smoking cessation and control of HTN, DM and dyslipidemia.
 Angiotensin-converting enzyme (ACE) inhibitors or
Angiotensin receptor blockers (ARBs) should be strongly
considered for antihypertensive therapy in patients with multiple
vascular risk factor
Stage B
 Patients with structural heart disease but no symptoms
 Tx by minimizing additional injury and preventing or showing the
remodeling process
 ACE inhibitors, ARBs (px intolerant to ACE), B-blockers

83. Stage C
 Initiation and titration of Diuretics, ACE inhibitor, and B-blocker
 If diuresis initiated and symptoms improved once the patient is
euvolemic, long term monitoring can begin.
 If symptoms do not improve, ARBs, Digoxin, or
Hydralazine/Isosorbide dinitrate (ISDN) may be used.
 Moderate sodium restriction, daily weight measurement,
immunization against influenza and pneumococcus, modest
physical activity, and avoidance of medications that can
exacerbate HF
Stage D
 specialized therapies including mechanical circulatory support,
continuous IV positive inotropic therapy, cardiac
transplantation, or hospice care

84. 2.a) What are the goals for the pharmacologic management
of heart failure in this patient?
 The therapeutic goals for chronic HF are to improve quality of
life, relieve or reduce symptoms, prevent or minimize
hospitalizations, slow disease progression, and prolong
survival.
Stage A:
 Identify and modify risk factors to prevent development of
structural heart disease and subsequent HF. Strategies include
smoking cessation and control of HTN, DM and dyslipidemia.
Desired Outcome

85. Stage B
 Patients with structural heart disease but no symptoms
 Tx by minimizing additional injury and preventing or showing the remodeling
process
 ACE inhibitors, ARBs (px intolerant to ACE), B-blockers
Stage C
 Initiation and titration of Diuretics, ACE inhibitor, and B-blocker
 If diuresis initiated and symptoms improved once the patient is euvolemic, long
term monitoring can begin.
 If symptoms do not improve, ARBs, Digoxin, or Hydralazine/Isosorbide dinitrate
(ISDN) may be used.
 Moderate sodium restriction, daily weight measurement, immunization against
influenza and pneumococcus, modest physical activity, and avoidance of
medications that can exacerbate HF
Stage D
 specialized therapies including mechanical circulatory support, continuous IV
positive inotropic therapy, cardiac transplantation, or hospice care

86. 2.b) Considering her other medical problems, what other
treatment goals should be established?
Non-pharmacological goals:
 Smoking cessation & avoidance to smoking areas
 Close monitoring on BP levels, sugar levels for HTN and
DM to eliminate worsening of HF
 Diet should also be managed

87. Pharmacological Goals:
For HTN-

88. 3) What medications are indicated in the long-
term management of this patient's heart failure
based on her stage of heart failure?
 Initiation and titration of Diuretics, ACE
inhibitor, and B-blocker
 If diuresis initiated and symptoms improved
once the patient is euvolemic, long term
monitoring can begin.
Therapeutic Alternatives

89. Diuretics
 Diuretic therapy in addition with sodium restriction for the fluid
retention
 Thiazide diuretics (hydrochlorothiazide) are relatively weak
diuretics and are used alone infrequently in HF. However,
thiazides or the thiazide-like diuretic metolazone can be used in
combination with a loop diuretic to promote effective diuresis.
 Thiazides may be preferred over loop diuretics in patients with
only mid fluid retention and elevated blood pressure because of
their more persistent antihypertensive effects

90. ACE inhibitor
 decrease angiotensin II and aldosterone, attenuating many of
their deleterious effects including reducing ventricular
remodelling, myocardial fibrosis, myocyte apoptosis, cardiac
hypertrophy, norepinephrine release, vasoconstriction, and
sodium water retention.
 Improve symptoms, slow disease progression, and decrease
mortality in patients with HF and reduced LVEF (stage C).

92. B-Blocker
 slow disease progression, decrease hospitalizations, and reduce
mortality
 antiarrhythmic effect, slowing or reversing ventricular remodelling,
decreasing myocyte death from catecholamine-induced necrosis or
apoptosis, preventing fetal gene expression, improving LV systolic
function, decreasing HR and ventricular wall stress thereby
reducing myocardial oxygen demand, and inhibiting plasma renin
release
 should be started in very low doses with slow upward dose titration
to avoid symptomatic worsening or acute decompensation.
Patients should be titrated to target doses when possible to provide
maximal survival benefits. However, even lower doses have
benefits over placebo, so any dose is likely to provide some
benefit.

93. 1. Carvedilol
3.125 mg twice daily (initially )
25 mg twice daily (target dose)
1. Metoprolol succinate
12.5 - 25 mg once daily (initally)
200 mg once daily (target dose)
3. Bisoprolol succinate
12.5 - 25 mg once daily (initially)
10 mg once daily (target dose)
 Dose-up titration is a long, gradual process and achieving the
target dose is important to maximize benefits.
 Responce to therapy may be delayed, and HF symptoms may
worsen during the initiation period.

94. 4.) What clinical and laboratory parameters are
needed to evaluate the therapy for achievement
of the desired therapeutic outcome and to detect
and prevent adverse events?
Mechanical Circulatory Support
1. Intraaortic Balloon Pump
2. Ventricular Assist Device
Surgical therapy
Outcome Evaluation

95. Intraaortic Balloon Pump
employes in patients with
advanced HF who do not
respond adequately to drug
therapy, such as those with
intractable myocardial ischemia
or patients in cardiogenic shock
support increase in cardiac index,
coronary artery perfusion, and
myocardial oxygen supply
accompanied by decreased
myocardial oxygen demand
IV vasodilators and inotropic
agents are generally used in
adjunct to maximize
hemodynamic and clinical
benefits

96. Ventricular Assist Device
 surgically implanted and assist the pumping functions of the
right or left ventricles
 can be used in short-term (days to several weeks) for
teemporary stabilization of patients awaiting an intervention to
correct the underlying cardiac dysfunction
 long term (several months to years) as a bridge to heart
transplantation.
 Permanent device implantation has recently become an option
for patients who are not candidate for heart transplantations

98. Surgical Therapy
 Orthotopic cardiac
transplantation-
best therapeutic
option for patients
with chronic
irreversible Class IV
HF
 10 yr survival of
approximately 50%
in well-selected
patients

99.  Shortage of donor hearts has
prompted developent of new
surgical techniques which have
resulted in variable degrees of
symptomatic improvement
1. Ventricular aneurysm
resection

100. 2. Mitral valve repair

101. 3. Myocardial cell transplantation

102. Clinical Course
Over the next 3 days, the patient receive maximal drug
therapy, and her condition improved. She was
discharged and was on:
Lisinopril 20mg po daily
Metoprolol 25mg po bid
Furosemide 40mg po daily
Aspirin 325mg po daily.
Clinical Course

103. 5.) What information should be provided to the patient about
the medications used to treat her HF?
Lisinopril (Zestoretic, Zestril)
 Essential in HTN px initially 10g & where combination therapy is
appropriate
Maintenance: 20mg as single daily dose
 Renovascular HTN :2.5 or 5mg, may be adjusted accding to BP response
 CHF: 2.5mg daily. Range: 5-20mg/day as single daily dose
 Acute MI: 5mg, 5mg after 24hr & 10mg after 48hr, 10mg once daily
thereafter
 Renal complication of DM: 10mg once daily. Incrase to 20mg once daily, if
necessary
Patient Education

104. Lisinopril (Zestoretic, Zestril)
 May or not be taken with meals
 ADR: Dizziness, headache, diarrhea, vomiting, fatigue, cough,
orthostatic effects and renal dysfunction
Metoprolol (Betaloc, Cardiosel, Neobloc, Betazok)
 Mild to moderate HTN: Adult 50mg once daily.
Max: 100-200mg once daily
 Angina pectores or Cardiac arrhythmias: 100-200mg once daily
 MI : Maintenance therapy 200mg once daily
 Functional heart disorder w/ palpiattions: 100mg once daily
 CHF: Initially 25mg once daily. May be doubled up to a maximum of
200mg once daily

105. Furosemide (Lasix)
 Edema due to cardiac, hepatic & renal disease; mild to
moderate HTN, hypersensitive crisis, acute HF, reduced
urinary output due to gestoses, chronic renal failure,
nephrotic syndrome
 Initially 1/2-1-2 tab daily. Maintenace 1/2-1 tab daily
 May be taken with meals to reduce GI discomfort
 ADR: symptomatic hypotension, dehydration,
hemoconcentration; hypokalemia, hyponatremia, metabolic
acidosis; increase blood lipid levels, urea, uric acid;
reduced glucose tolerance, hearing disorder; pancreatitis;
GI symptoms; anaphylactic reactions

106. Aspirin (Aspilets/Aspilets-EC)
 Prophylactic tx of thromboembolic disorders, MI, transient ischemic
attacks(TIA) & stroke. Secondary prevention of cerebrovascular
events in patients with DM esp those with history of MI, TIA or minor
stroke, angina and those with additional risk fators; HTN, smoking,
dyslipidemia & family history of CV disease; reinfarction in patients
with previous MI; restenosis of CABG
 Ischemic stroke & TIA: 50-325 mg once daily
 Suspected acute MI: Initial dose 160mg
Maintenance dose 160mg/daycontinue for 30 days post-MI
 Prevention of recurrent MI, unstable angina pectoris & cronic
unstable anginactoris & chronic stable angina pectoris, primary &
secondary prevention of CV events in patients w/ DM: 75-325mg
once daily

107.  Take immediately after meals w/ a full glass of water
unless patient is fluid-restricted. Swallow whole, do
not chew/crush/bite the tab
 ADR: fever, hypothermia, thirst. Agitation, cerebral
dema, coma, confusion, dizziness, headache,
lethargy, seizure