1. Heart Failure Done by : Taqwa shaban Amal razmak Aya hamad
Amal al-jarrah

2. Heart failure: Systolic HF (( systolic dysfunction)) :
HF is a complex clinical syndrome that results from any structural or functional impairment of ventricular filling or ejection of blood.
Systolic HF (( systolic dysfunction)) :
* Impaired ejection
* Decreased contractility

3. Signs and symptoms :
- Low EF (<45%) - Cardiomegaly - S3 - Normal wall thickness - Hypokinesis - Symptoms primarily those of reduced cardiac output

4. Chief Complaint
“I’ve been more short of breath lately. I can’t seem to walk as far as I used to, and either my feet are growing or my shoes are shrinking!”

5. History Of Present Illness (HPI)
Rosemary Quincy is a 68 yo African-American female who presents to her family medicine physician for evaluation of her shortness of breath and increased swelling in her lower extremities.
She reports that her shortness of breath has been gradually increasing over the past 4 days.
She has noticed that her shortness of breath is particularly worse when she is lying in bed at night, and she has to prop her head up with three pillows in order to sleep.
She also reports exertional dyspnea that is usual for her, but especially worse over the past couple of days.

6. Past Medical History (PMH)
-Hypertension × 20 years
-CHD with history of MI in 2005 (PCI performed and bare metal stents placed in LAD and RCA)
-Heart failure (NYHA FC III)
-Type 2 DM × 25 years
-Atrial fibrillation
-COPD (stage 3)

7. Family History (FH)
Father died of lung cancer at age 71, mother died of MI at age 73

8. Social History (SH) Reports occasional alcohol intake.
States she has been trying to follow her low-cholesterol and low-sodium diet.
Former smoker (35 pack-year history; quit approximately 10 years ago).

9. Medications ( Meds) : -Valsartan 160 mg po BID
-Furosemide 40 mg po BID
-Warfarin 2.5 mg po once daily
-Carvedilol mg po BID
-Pioglitazone 30 mg po once daily
-Glimepiride 2 mg po once daily
-Potassium chloride 20 mEq po once daily
-Atorvastatin 40 mg po once daily
-Aspirin 81 mg po once daily
-Albuterol MDI, two inhalations by mouth q 4–6 hours PRN shortness of breath
-Tiotropium DPI 18 mcg, one inhalation by mouth daily
-fluticasone/salmeterol DPI 250 mcg/50 mcg, one inhalation by mouth BID

10. INDICATION CLASS DOSING DRUGs
HT & HF (PCI)
ARBs
160 mg po BID
Valsartan
HT & HF
Loop Diuretic
40 mg po BID
Furosemide
Prophylaxis
(PCI)
Anticoagulant Vitamin K Antagonist
2.5mg po once daily
Warfarin
HF, MI & Atrial fibrillation
B-blocker
3.125 mg po BID
Carvedilol
Type 2 diabetes
Antidiabetic agent (Thiazolidinedione)
30 mg po once daily
Pioglitazone
Antidiabetic agent (Sulfonylurea)
2 mg po once daily
Glimepiride
Prevention of hypokalemia
Electrolyte supplement
20 mEq po once daily
Potassium chloride
CHD
Antilipemic Agent
40 mg po once daily
Atorvastatin
MI (PCI)
Antiplatelet agent(NSAID)
81 mg po once daily
Aspirin

11. INDICATION
CLASS
DOSING
DRUGs
Bronchospasm
B2 Agonist
2 inhalations q 4_6 h PRN shortness of breath
MDI Albuterol
COPD
Anticholinergic Agent (long acting)
1 inhalations daily
Tiotropium DPI 18 mcg
B2 Agonist (long acting)
1 inhalations BID
Fluticasone/ Salmeterol DPI 250 mcg/50mcg

12. Review of symptoms (ROS)
- Approximate 7-kg weight gain over the past week.
- worsening shortness of breath with exertion and three-pillow orthopnea.
- chronic, dry (nonproductive), hacking cough, which she describes as usual without recent worsening.

13. Physical Examination General
African-American female in moderate respiratory
distress
( Vital sign (VS
BP 134/76 mm hg (sitting; repeat 138/80),
HR 65 (irreg irreg)=> normal
respiratory rate (RR) 24 => normal (16-20)
, T 37°C,
O2 sat 90% RA,
Ht 5′5″ = cm ,
Wt 79 kg (Wt 1 week ago: 72 kg)

14. Skin
Color pale and diaphoretic; no unusual lesions noted
Head, Eyes, Ears, Nose and Throat (HEENT)
PERRLA;
Pupils,Equal,Round,Reactive to
Light ,Accommodation
lips mildly cyanotic;
dentures

15. Neck
(+) JVD (Jugular Venous Distention) at 30° (7 cm) => normal <4 cm
; no lymphadenopathy or thyromegaly
Lungs/Thorax
Crackles bilaterally, 2/3 of the way up; no expiratory wheezing
Heart
Irregularly irregular; (+) S3; displaced PMI

16. Abdomin
Soft, mildly tender, nondistended; (+) HJR ( hepatojugular reflux); no masses, mild hepatosplenomegaly; normal BS
Genit/Rect
Guaiac (−), genital examination not performed
MS/Ext
3+ pitting pedal edema bilaterally; radial and pedal pulses are of poor intensity bilaterally
Neuro
A & O × 3 (alert & oriented to person,place,time), CNs intact. No motor deficits

17. ECG
Atrial fibrillation, LVH
Chest X-Ray
evidence of congestive failure with cardiomegaly, interstitial edema, and some early alveolar edema. There is a small right pleural effusion.
No evidence of infiltrates; evidence of pulmonary edema suggestive of congestive heart failure; enlarged cardiac silhouette
Echocardiogram
LVH, reduced global left ventricular systolic function, estimated EF 20%; evidence of impaired ventricular relaxation, Stage 1 diastolic dysfunction

18. Labs Na 131 mEq/L (135-145) Hgb 13 g/dL (13-17) Mg 1.9 mEq/L (1.5-2)
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Labs
Na 131 mEq/L ( )
Hgb 13 g/dL (13-17)
Mg 1.9 mEq/L (1.5-2)
INR 2.3 (2-4)
K 3.5 mEq/L (3.5-5)
Hct 40% (37-52)
Ca 9.3 mg/dL ( )
HbA1C 6.1% ( )
Cl 99 mEq/L (95-105)
( )
Plt 192 × 103/mm3
Phos 4.3 mg/dL ( )
CO2 28 mEq/L (23-30)
(4-10)
WBC 9.1 × 103/mm3
AST 34 IU/L (8-46)
BUN 32 mg/dL (5-20)
ALT 27 IU/L (7-55)
SCr 2.3 mg/dL (baseline SCr 2.1 mg/dL) ( )
Glucose 124 mg/dL (70-100)
BNP 776 pg/mL (BNP drawn 2 months prior: 474 pg/mL) (<100)

19. Labs CCl = 24.2 Normal range Result Test 135-145 131 Na 5-20 32 BUN
2.3
SCr
70-100
124
glucose
<100
776
BNP
4.3
Phos
6.1%
HbA1c
CCl = 24.2

20. Assessment
Admit to hospital for acute exacerbation of heart failure.
Clinical Pearl
The presence of pitting edema is associated with a substantial increase in body weight; it typically takes a weight gain of 10 lb to result in the development of pitting edema.

21. Questions

22. Drug-Drug Interactions
Create a list of this patient’s drug-related problems ?
Drug-Drug Interactions
Related issue
Salmeterol with carvedilol
B2 agonist with mixed B antagonist worsen dyspnea
Warfarin with Aspirin
May lead to bleeding
Pioglitazone
Exacerbate heart failure

23. 1.b. What signs, symptoms, and other information indicate the presence and type of heart failure in
? this patient
signs
symptoms
Shortness of breath over the
past 4 days .
Increased swelling in the lower extremities.
Exertional dyspnea.
HR 65 (irreg.irreg)
Displaced PMI
S3 sound present
Cardiomegaly
3+ pitting pedal edema
Interstitial edema
Early alveolar edema
Small right pleural effusion
Skin color pale & diaphoretic.

24. stage 4 according to ( NYHA Functional Classification).
What is the classification and staging of chronic heart failure for this patient
stage 4 according to ( NYHA Functional Classification).
She has acute exacerbation of heart failure with left systolic dysfunction.

25. Could any of this patient’s problems have been caused by drug therapy?
Pioglitazone is a 1ST generation sulfonurea which exacerbate heart failure and cause pedal edema with weight gain.
And intake of carvedilol with B2 agonist
worsening of COPD by antagonism.
There is also a glimepiride which increase CV
mortality.

26. 2.a.
What are the goals for the pharmacologic management of heart failure in this patient?
Control the disease and prolonging survival by improving quality of life .
Relief symptoms of dyspnea & orthopnea .
Decrease edema & swelling.
Fluid restriction & Minimizing disability.
Manage the acute exacerbation of her HF.

27. 3.a.
What diuretic therapy should be recommended for this patient initially for acute treatment of her heart failure exacerbation?
Use the same diuretic which is furosemide but in IV/IM: 10 to 20 mg once over 1 to 2 minutes. A repeat dose similar to the initial dose may be given within 2 hours if there is an inadequate response. Following the repeat dose, if there is still an inadequate response the last IV dose may be raised by 20 to 40 mg until there is an effective diuresis.
Single doses NOT exceeding 200 mg.

28. 3.b.
How should this patient’s pharmacotherapy be adjusted for chronic management of her heart failure?
Change B blocker to metoprolol succinate to prevent interaction with b2 agonist which is salmeterol.
Titrate furosemide oral dose to 80 mg( max 600)
Warfarin dosage should adjusted according to results of International Normalized Ratio (INR) or prothrombin time (PT).
Increase the dose of glimepiride after stopping pioglitazone .

29. Continue on Warfarin and Aspirin.
For HTN management associated with heart faliure :
Continue on valsartan& furosemide
:For atrial fibrillation
It managed by warfarin & carvedilol that replaced with metoprolol succinate.
:For Dyslipidemia
Continue on atorvastatin.
For COPD management :
Continue on albuterol ,tiotropium,
Continue on fluticasone /salmetrol
For hypokalemia :
Continue on pottasium chloride supplements with monitoring

30. 3.c.
What non pharmacologic therapy should be recommended for this patient with respect to her heart failure?
Dietary modifications such as low sodium & cholesterol diet.
Risk factor reduction including stopping alcohol consumption and supervised regular physical activity.
O2 therapy to be >90% if the pt has hypoxia.
bed rest during exacerbation .
Fluid restriction.

31. 4. What drugs, doses, schedules, and duration are best suited for the management of this patient?
Initial Daily Dose(s)
Maximum Dose(s)
Duration of action
Metoprolol succinate
extended release
12.5 to 25 mg once
200 mg once
24 hr
Furosemide
20 to 40 mg once or twice
600 mg
6 to 8 h
valsartan
40 mg twice daily
80 to 160 mg once daily

32. 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?
Initially monitor patient for rapid relief of symptoms related to the chief complaint of orthopnea, dyspnea , oxygenation & fatique.
Monitor for adequate perfusion of vital signs:
asses mental status , Cr Cl , stable HR btw HR/min,BP.
Monitor kidney& liver function.
monitor blood glucose
Fluid intake – body weight (daily)-

33. Metoprolol succinate:
BP, HR baseline and after Carvedilol mg twice 25 mg twice each dose titration, ECG
Furosemide :
monitor electrolyte ,hyperuricemia , nephrotoxicity & autotoxicity.
Valsartan :
Monitor potassium and serum creatinine

34. 6. What information should be provided to the patient about the medications used to treat her heart failure?
Furosemide taking on empty stomach
Grapefruit juice can increase the blood levels of Atorvastatin. This can increase the risk of side effects such as liver damage
Take Metoprolol at the same time each day, preferably with or immediately following meals
Avoid taking potassium rich food.
Glimepiride should be administered with breakfast or the first main meal.

35. Pharmacist Care Plan (PCP)

36. Pharmacotherapy goals Tx issues Medical problem Date
Physician action
Recommendations
Pharmacotherapy goals
Tx issues
Medical problem
Date
Start on metoprolol succenate initial 12.5 mg BID Take Furosemide iv 40 mg with gradual increment, when stable back to po 80 mg BID continue on valsartan 160 mg po BID continue on warfarin 2.5 mg po once daily continue on aspirin 81 mg po once daily
Manage symptoms, Increase survival and QOL.
Acute exacerbation of systolic HF inadequately drug therapy HF
8/10
Increase Furosemide oral dose to 80 mg Continue on valsartan And metoprolol succenate as described above
Bp<120/80
Bp above goal
HTN
Stop pioglitazone and increase glimpiridine to 8 mg.
Decrease glucose to 100mg/ dl
Blood glucose above goal DM
Continue on Atorvastatin 40 mg po once daily
Decrease LDL and increase HDL
Increased lipids
Dyslipidemia
Continue on Albuterol MD2 inhalation q 4-6 hours continue on tiotropium DPI 18 mcg, continue on fluticasone/salmetrol DPI 250 mcg/ 50mcg, h inhalation BID.
Decrease chronic cough and hacking cough (enhancing breathing)
stable
COPD management
Manage by warfarin 2.5 mg and carvedilol mg( replaced with metoprolol succinate).
Continue to be managed
Atrial fibrillation

37. comments
Achievement of outcomes
Freq
Monitoring parameters
Goals
Every visit till steady
electrolytes: Na K HF
Every visit
BNP
SCr
Every day
BP HR
HTN
Sugar level DM
Daily once a week
Weight HDL, LDL, TG
Dyslipidemia HR
Atrial fibrillation
Breathing, Coughing
COPD

38. comments
Achievement of outcomes
Freq
Monitoring parameters
Goals
Every visit
Monitor pottasium and SCr
Valsartan
Monitor electrolytes ( Na/K, hyperuricemia, nephrotoxicity and autotoxicity)
Furosemide
Daily once a month
BP, HR baseline and ECG
Metoprolol succinate

39. THE END