1. CHF, COPD, And Diabetes Simple Pathophysiology, Common Treatments, and Signs/Symptoms of Decompensation

2. Lecture Summary Congestive Heart Failure  Pathophysiology  Medications  Signs of worsening illness Chronic Obstructive Pulmonary Disease  Pathophysiology  Signs of COPD exacerbation Diabetes  Pathophysiology  Acute diabetic complications General Thoughts About Compliance

3. Lecture Teaching Philosophy Understand the basics of what is happening in the body as a basis for understanding the effects of medications and the potential for complications. This is an interactive lecture. Please ask questions, stop me when you don’t understand, and question me when you think I am wrong. Be prepared for me to ask you for input!

4. “Healing is a matter of time, but it is sometimes also a matter of opportunity” Hippocrates

5. Disclaimer We are not a home health service. We do not give medical advice. We solve healthcare problems and help implement care plans.

6. Congestive Heart Failure

7. CHF Definition Heart failure in which the heart is unable to maintain adequate circulation of blood in the tissues of the body or to pump out the venous blood returned to it by the venous circulation

8. Causes of Heart Failure Coronary Artery Disease Hypertension Cardiomyopathy Arrhythmias Heart Valve Abnormalities Congenital Defects

9. Circulation Two Circulations – systemic and pulmonary Right sided heart failure results in increased “backup” (preload) and edema. Left sided heart failure results in decreased perfusion of tissues. There are types Systolic Failure Diastolic Failure

10. Reasons to Suspect Worsening CHF Unexplained change in weight — if you gain or lose more than or equal to 4 pounds from your dry weight. Increased swelling in your ankles, feet, legs, or abdomen Shortness of breath (difficulty breathing) that is new, has become worse, or occurs more often, especially if it occurs when you are at rest or when you wake from sleep feeling short of breath A feeling of fullness (bloating) in your stomach Extreme tiredness or decreased ability to complete daily activities A respiratory infection or a cough that has become worse Coughing during the night

11. Reasons to Suspect Worsening CHF Decreased urination, dark urine Restlessness, confusion Constant dizziness or lightheadedness Nausea or poor appetite Vomiting Chest pain or discomfort during activity that is relieved with rest Changes in sleep patterns, including difficulty sleeping or needing to sleep a lot more than usual Fast heart rate - at or over 120 beats per minute while at rest A new or a more noticeably irregular heartbeat Any other symptom that causes stress or concern

12. When to Seek Immediate Help CHF New chest pain or discomfort that is severe, unexpected and occurs with shortness of breath, sweating, nausea or weakness Angina-type chest pain that lasts longer than 15 minutes and is not relieved by rest and/or medication (nitroglycerin) Fast heart rate (more than 120 -150 beats per minute), especially if you are short of breath or dizzy Shortness of breath NOT relieved by rest Sudden weakness or paralysis (inability to move) in your arms or legs Sudden onset of a severe headache Fainting spell with loss of consciousness

13. CHF Medications Anticoagulants Antiplatelet Agents Angiotensin-Converting Enzyme Inhibitors Angiotensin II Receptor Blockers Beta Blockers Calcium Channel Blockers Diuretics Vasodilators Digitalis Preparations

14. Anticoagulants Common Names Warfarin (Coumadin) Heparin Enoxaparin (Lovenox) Effect(s) of Medication Helps prevent clots in blood vessels Prevents/reduces risk of first or recurrent stroke Slows clot propagation

15. Antiplatelet Agents Common Names Aspirin Clopidogrel (Plavix) Ticlopidine Dipyridamole Effect(s) of Medication Helps prevent clots in blood vessels Prevents/reduces risk of first or recurrent stroke Reduces risk of MI and improves survivability if MI occurs

16. Renin Angiotensin Aldosterone System

17. Angiotensin-Converting Enzyme (ACE) Inhibitors Common Names Benazepril (Lotensin) Captopril (Capoten) Enalapril (Vasotec) Fosinopril (Monopril) Lisinopril (Pirinivil, Zestril) Ramipril (Altace) Effect(s) of Medication Decreases BP (Reduces afterload) Repairs damaged heart tissue (cardiac remodeling)

18. Angiotensin-2 Receptor Blockers (ARB’s) Common Names Candesartan (Atacand) Irbesartan (Avapro) Losartan (Cozaar) Valsartan (Diovan) Effect(s) of Medication Decreases BP (Reduces afterload) Repairs damaged heart tissue (cardiac remodeling)

19. Beta Blockers Common Names Atenolol (Tenormin) Metoprolol (Lopressor, Toprol) Propranolol (Inderal) Effect(s) of Medication Decreases BP (Reduces afterload) Treats arrhythmias Reduces incidence of MI

20. Calcium Channel Blockers Common Names Amlodipine (Norvasc, Lotrel) Diltiazem (Cardizem, Tiazac) Felodipine (Plendil) Nisoldipine (Sular) Verapamil (Calan, Isoptin, Verelan) Effect(s) of Medication Decreases BP (Reduces afterload) Treats some arrhythmias Reduces angina

21. Diuretics Common Names Bumetanide (Bumex) Chlorothiazide (Diuril) Furosemide (Lasix) Hydro-chlorothiazide Indapamide (Lozol) Spironolactone Effect(s) of Medication Decreases Volume of Fluid (reduces preload) Helps reduce BP Decreases pulmonary edema

22. Vasodilators Common Names Nitrates Minoxidil Hydralazine (Apresoline) Nesiritide (Natrecor) Effect(s) of Medication Relaxes blood vessels Increases cardiac blood flow Used to decrease chest pain (angina)

23. Digitalis Preparations Common Names Lanoxin Effect(s) of Medication Increases cardiac contractility Treats some arrhythmias (especially atrial fibrillation) Used when ACE-I and diuretics fail to work (truly second line therapy)

24. “One of the first duties of the physician is to educate the masses not to take medicine.... Soap and water and common sense are the best disinfectants.” Sir William Osler

25. CHF Lifestyle Modifications Losing or maintaining your weight Tracking daily fluid intake Avoid alcohol Limit caffeine Be physically active Manage stress Select appropriate clothing Keep up to date on vaccinations (especially flu and pneumococcal)

26. Chronic Obstructive Pulmonary Disease

27. Obstructive vs. Restrictive Lung Disease Obstructive Emphysema Chronic Bronchitis Asthma Bronchiectasis Cystic Fibrosis Restrictive Interstitial Lung Disease (Pulmonary Fibrosis) Sarcoidosis Obesity Scoliosis Neuromuscular Disease

28. COPD – Obstruction of Flow Inflammation, mucus, and bronchoconstriction contribute to increased work of breathing.

29. Causes of COPD Long-term cigarette smoking Genetic predisposition (only 20% of smokers develop COPD!) Alpha-1-antitrypsin deficiency (about 1% of the population) Other irritants such as cigar smoke, secondhand smoke, air pollution, dust/fumes/smoke from industrial sources

30. Mark Twain “Giving up smoking is the easiest thing in the world. I know because I've done it thousands of times.”

31. Does smoking cessation improve morbidity and mortality? Should you encourage cessation even in long term smokers???

33. 10 Signs of COPD Exacerbation When to seek help for COPD

34. Shortness of Breath (SOB) “Breathless” “Just not getting enough air” SOB at rest or little physical activity

35. Noisy Breathing Wheezing Whistling Gurgling Rattling

36. Increased anxiety Due to lack of oxygen “Anxious” “Panicky” Worse as muscles fatigue

37. Chest Breathing Breathing from the chest (instead of the abdomen) Use of accessory muscles of respiration Irregular breathing patterns

38. Cough Cough that is more frequent or severe than usual Change in cough character Cough increasing when lying down

39. Change in skin or nail color Pale Bluish around lips Blue or purple nail beds Skin may even take on a sallow gray tone

40. Difficulty sleeping or no interest in eating Body working so hard to breathe, it cant afford to shift blood to gut for digestion Decreased oxygen content does not allow for stage 4 sleep patterns

41. Inability to Speak Patient may be unable to produce enough force to vibrate vocal cords and therefore cannot speak

42. Early Morning Headaches Low oxygen levels frequently result in headaches – especially in the morning. Due more to the buildup of CO2 in the blood. If a new symptom, could be a subtle clue the O2 levels are low.

43. Swelling of the Ankles or Legs Usually secondary to the lungs affecting the heart (especially the right side of the heart) – also known as cor pulmonale

44. When to Seek Immediate Help for Patients with COPD Cough up ½ cup or more of blood Have new chest pain SOB or wheezing that is quickly getting worse Coughing more deeply, especially if you notice a change in the color of the sputum or an increase in mucous Increased swelling of the legs or belly High fever (>101) Develop flu-like symptoms

45. Diabetes Mellitus Complications and Control

46. How does insulin work in the body?

47. Comparison of Types of Diabetes Type I DM Onset sudden Any age, but mostly in young Thin or normal weight Common to develop DKA Autoantibodies usually present Endogenous insulin is low or absent Genetic predisposition 50% Only 5 – 10% of US diabetic population Type II DM Gradual onset Mostly adults Often obese Rare incidence of DKA No autoantibodies Normal, increased, or decreased endogenous insulin 90% genetic (twins) 90-95% of US population

48. Diabetes Complications Multiple sites of damage directly related to elevated blood glucose causing both macro vascular and micro vascular damage. End organ failure occurs secondary to the vascular compromise.

49. Acute Complications of Diabetes Short term dangers requiring medical attention.

50. Hypoglycemia Hypoglycemia is a medical emergency that involves an abnormally diminished content of glucose in the blood. The level of blood glucose low enough to define hypoglycemia differs with individual patients. Criteria (Whipple’s triad) used to determine hypoglycemia in an individual:  1. Symptoms known to be caused by hypoglycemia  2. Low glucose at the time symptoms occur  3. Reversal or improvement of symptoms or problems when the glucose returns to normal.

51. Causes of Hypoglycemia Medications, medications, medications Excessive alcohol consumption (ETOH blocks liver from releasing stored glucose) Liver disease (hepatitis) Renal failure Anorexia Insulin overproduction (insulinoma) Endocrine deficiencies (adrenal and pituitary issues) – more common in children

53. DKA Diabetic Ketoacidosis occurs when lack of insulin results in anaerobic respiration and mobilization of stored glucose. This results in free fatty acid metabolism and the creation of ketones.

54. Signs/Symptoms of DKA Excessive thirst Frequent urination Nausea and vomiting Abdominal pain Weakness or fatigue Shortness of breath Fruity-scented breath Confusion

55. Infection Cellulitis and ulceration

56. Diabetic Infections In general, infectious diseases are more frequent and/or serious in patients with DM, which potentially increases morbidity and mortality.

57. Diabetes affects many aspects of the immune response

58. Increased rate of infection in DM

59. Common infections in diabetics Foot infections Malignant otitis externa Upper respiratory infections Gangrenous cholecystitis

60. Compliance What motivates us to improve?

62. Mark Twain But who prays for Satan? Who, in eighteen centuries, has had the common humanity to pray for the one sinner that needed it most?

63. “I’m exhausted trying to stay healthy” Steve Yzerman

64. Thank you Questions????