Hypertension/Heart Failure Discussion Essays
Module X: Hypertension/Heart Failure Discussion Must post first. Subscribe 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. 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. ? Feedback 94 / 100 View Graded Rubric Start a New Thread Discussion Filter by: All Threads Sort by: Most Recent ActivityLeast Recent ActivityNewest ThreadOldest ThreadAuthor First Name A-ZAuthor First Name Z-AAuthor Last Name A-ZAuthor Last Name Z-ASubject A-ZSubject Z-A Module 10: Heart Failure Jessica Faltinowski posted Nov 4, 2020 7:49 PM Subscribe Module 10:? Heart Failure 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. 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.? 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. ? 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 more 0 Unread 0 Unread 1 Replies 1 Replies 7 Views 7 Views View profile card for Gisselle Mustiga Last post?Nov 8, 2020 11:40 PM?by Gisselle Mustiga Module X ? Candace Whitman-Workman Contains unread posts Candace Whitman-Workman posted Nov 4, 2020 9:54 PM Subscribe 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. 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. 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 more 1 Unread 1 Unread 1 Replies 1 Replies 6 Views 6 Views View profile card for Jessica Faltinowski Last post?Nov 8, 2020 10:38 PM?by Jessica Faltinowski Module X: HTN and HF Shante Hunt posted Nov 4, 2020 6:48 PM Subscribe 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. ? 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 ? ? less 0 Unread 0 Unread 2 Replies 2 Replies 4 Views 4 Views View profile card for Candace Whitman-Workman Last post?Nov 8, 2020 7:19 PM?by Candace Whitman-Workman Discussion 10 Contains unread posts Dianne Cohen posted Nov 5, 2020 12:57 AM Subscribe 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.?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 more 1 Unread 1 Unread 1 Replies 1 Replies 7 Views 7 Views View profile card for Shante Hunt Last post?Nov 8, 2020 2:37 PM?by Shante Hunt Module 10 Anna McMullen posted Nov 2, 2020 11:31 AM Subscribe 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). 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). 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). ? 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 more 0 Unread 0 Unread 1 Replies 1 Replies 5 Views 5 Views View profile card for Kathryn Mosholder Last post?Nov 8, 2020 10:01 AM?by Kathryn Mosholder MODULE X: Hypertension/Heart Failure Discussion Contains unread posts Augusta Ibeh posted Nov 4, 2020 8:35 PM Subscribe ??????????? 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
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