1. Heart Failure pharmacist care plan By: Dalya Abu Al-Sindyan
Lina Darwish Msllam

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

3. History Of Present Illness (HPI)
Rosemary is a sixty eight years old African-American female, she report that her shortness of breath has been gradually increasing over the past four days and it is particularly worse when she is lying in bed at night and she also reports exertional duspnea that is usual for her and increased swilling in her lower extremities.

4. PMH Hypertension X 20 years. CHD with history of MI in 2005.
HF (NYHA FC III).
DM type 2.
Atrial Fibrillation
COPD (Stage 3)

5. Family History Father died of lung cancer at age 71.
Mother died of MI at age 73.

6. Social History Alcohol intake. Low cholesterol and sodium diet.
Former smoker.

7. Medications Valsartan 160 mg po BID. Furosemide 40 mg po BID.
Carvedilol mg po BID.
Warfarin 2.5 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, 2 inhalations q 4-6 hours PRN shortness of breath.
Tiotropium DPI 18 mcg /50 mcg, 1 inhalations BID
Pioglitazone 30 mg po once daily.

8. ROS Seven kg weight gain over the past week.
Worsening shortness of breath.
Orthopnea chronic, dry hacking cough.

9. Physical Examination GEN: VS: Skin: HEENT: Nick: Lungs:
African-American female in moderate respiratory distress.
VS:
BP 134/76 (Sitting 138/80), HR 65, RR 24, T 37 ºC, O2 sat 90% RA, WT 79 kg.
Skin:
Color pale and diaphoretic.
HEENT:
PERRLA lips mildly cyanotic; dentures.
Nick:
JVD at 30º (7 cm).
Lungs:
Crackles bilaterally.
Echocardiogram:
LVH reduced global left ventricular systolic function, EF 20%
Heart:
Irregularly Irregularl (s3); displaced PMI.
APD:
Soft, myldlu tender, nondistended, (+) HJR.
GENIT/RECT:
Guaiac (-).
MS/EXT:
3+ pitting pedal edema bilaterally.
NEURO:
A & O x 3, CNs intact. No motor deficts.
ECG:
Atrial fibrillation, LVH.
Chest X-Ray:
pleural effucion, evidence of pulmonary edema.

10. Discussion Create a list of this patient drug related problems
Drug-Drug Interactions
Related issue
solution
Salmetrol with carvediolol
B2 agonist with mixed b antagonist worsen dysponea
Replace carvediolol with selective cardiotonic nebivolol
Warfarin with Aspir
May lead to bleeding
Give small dose with monitor
Pioglitazone
Excerbate heart faliure
Stop it

11. Signs & Symptoms
What signs symptoms & other information indicate the presence and type of heart failure in this patient?

12. Signs Shortness of breath for the last 4 days .
Increased swelling in lower extremities.
Exertional dyspnea.
Note:
These are symptoms of Left sided-HF & listed as stage ii /iii HF (NYHA functional classification) or stage C (ACC/AHA(38)

13. Symptoms HR 65 (irreg irreg), displaced PMI
S3 sound present.(systolic HF)
3+ pitting pedal edema , Alveolar edema
Decreased pleural effusion.
Skin color pale & diaphoretic.

14. Physical Examination Labs: BNP greater than 100 pg/mL (776pg/ml).
ECG Atrial fibrillation ,and LV hypertrophy.
Nick: JVD at 30 is a result of right side HF
Lungs bilateral crackles result from CHF.

15. Heart Failure Classification
What is the classification of heart failure in this patient ?
stage ii /iii systolic HF (NYHA functional classification) or stage C (ACC/AHA(38))
Stage I of diastolic HF.
She has acute exacerbation of heart failure with left systolic dysfunction.

16. Patient Problems Causes
Could any of this patient problems have been caused by drug therapy ?
Pioglitazone which is 1ST generation sulfonurea tend to exacerbate heart failure (BB C.I) in symptomatic patients & cause edema , weight gain,also glimperide increase CV mortality.
Intake of carvediolol with b2 agonist causes antagonism and worsening of COPD..

17. Goals For Pharmacologic Management Of HF
What are the goals for pharmacologic management of HF in this patient?
Slowing progression of the disease, improving quality of life, and prolonging survival reducing long-term risk for hospitalizations
Alleviating fluid retention, minimizing disability.
Relief symptoms of dyspnea & orthopnea .
Decrease edema & swelling.
Manage acute exacerbation of her HF.

18. Diuretic Therapy
What diuretic therapy should be recommended for this patient initially for acute tx of HF exacerbation?
Use the same diuretic she takes furosemide as I.V.: mg/dose, may be repeated in 1-2 hours as needed and increased by 20 mg/dose with each succeeding dose up to 1000 mg/day; usual dosing interval: 6-12 hours [ACC/AHA guidelines ]

19. Pharmacotherapy
How should this patient pharmacotherapy be adjusted for chronic management of her systolic heart failure ?
Change B blocker to metoprolol succinate to prevent interaction with b2 agonist
Titrate furosemide oral dose to 80 mg( max 600)
Warfarin dosage should be based on INR (2-3)or prothrombin level
Increase the dose of glimperide after stopping pioglitazone

20. Non Pharmacologic Therapy
What non pharmacologic therapy should be recommended for this patient with respect to her HF?
Cha dietary modifications such as sodium and fluid restriction & low cholesterol diet.
Risk factor reduction including stopping alcohol consumption, timely immunizations, and supervised regular physical activity.
Stop alcohol intake as it causes heart poisoning: bed rest & o2 therapy to enhance acute phase.

21. Drug Plan
What drugs, doses ,schedules & duration of action are best suited for the management of this patient ?
Drug
Initial Daily Dose(s)
Maximum Dose(s)
scaduals
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

22. Drug Plan Continue on Warfarin 2.5 mg PO 1ce/day.
What non pharmacologic therapy should be recommended for this patient with respect to her HF?
Continue on Warfarin 2.5 mg PO 1ce/day.
Continue on aspirin 81 mg po once daily.
HTN management associated with heart faliure :
Continue on valsartan 160 mg po BID.
Continue on furosemide 40 mg po BID.
Atrial fibrillation:
Managed by warfarin 2.5 mg & carvedilol 3.125mg (replaced with metoprolol succinate)
Dyslipidemia:
Continue on atorvastatin 40 mg po 1ce daily.

23. Drug Plan DM Type ii management:
Use insulin glargine 36 U subQ daily
Use insulin lispro 12 U subQ TID with meals.
COPD management :
Continue on albuterol MDI 2 inhalation q 4-6 hr
Continue on tiotropium DPI 18 mcg, 1/day
Continue on fluticasone /salmetrol DPI 250 mcg/50 mcg, 1 inhalation BID.
Hypokalemia :
Continue on pottasium supplements with monitoring specially with furosemide IV.

24. Alternative Plan
Add direct vasodilator as 1st line therapy for her HF b/c it has advantage in African American over ACE-I & ARB’s which c/I in this case due to presence allergy cough edema hyperkalemia & renal impairment : use Isosorbide Dinitrate and hydralazine in comb : BiDilآ®
No need to add digoxin for Afib as it’s managed.
Can’tAdd spirlonlactone as it’s adviced for stage iii HF because crcl

25. Clinical & Laboratory Parameters
What clinical & 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 , liver function test and a stable HR btw HR/min,BP.
Monitor kidney& liver function.
monitor blood glucose
Fluid intake – body weight (daily)-

26. Monitor Adverse Effect Of Drugs
What clinical & laboratory parameters are needed to evaluate the therapy for achievement of the desired therapeutic outcome and to detect and prevent adverse events?
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

27. information should be provided
What information should be provided to the patient about medication used to treat her HF ?
Furosemide taking on empty stomach
Digoxin: do not discontinue without consulting prescriber.
Grapefruit juice can increase the blood levels of Atorvastatin. This can increase the risk of side effects such as liver damage

28. Information Should Be Provided
What information should be provided to the patient about medication used to treat her HF ?
Furosemide taking on empty stomach
Digoxin: do not discontinue without consulting prescriber.
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.

29. Pharmacotherapy goals
PCP
Date
Medical proplem
Tx issue
Pharmacotherapy goals
recommendations
Physician action
8/10 HF
Acute exacerbation of Systolic HF
Inadequate drug therapy
Manage symptoms increase survival & QOL.
Start on metoprolol succenate initial 12.5 mg BID
Take furosemide Iv 40mg with gradual increment , when stable back to PO 80mg BID
Continue on valsartan 160mg po BID
Continue on Warfarin 2.5 mg PO 1ce/day.
Continue on aspirin 81 mg po1ce
HTN
BP above goal
BP<120/80
Increase furosemide oral dose to 80mg.
Continue on valsartan & metoprolol succenate as described above. DM
Blood glucose above goal
Decrease glucose to 100mg/dl
Stop pioglitazone & increase glimpiride to 8mg
Dyslipidemia
Increased lipids
Decease LDL & increase HDL.
Continue on atorvastatin 40 mg po 1ce daily
COPD management
stable
Decrease chronich cough & hacking cough,, enhance breathing.
Continue on albuterol MDI 2 inhalation q 4-6 hr
Continue on tiotropium DPI 18 mcg, 1/day
Continue on fluticasone /salmetrol DPI 250 mcg/50 mcg, 1 inhalation BID.
Atrial fibrillation
Continue to be managed
Managed by warfarin 2.5 mg & carvedilol 3.125mg (replaced with metoprolol succinate)

30. PCP Dyslipidemia Goals Monitoring parameters Freq
Achievements of outcomes
comments HF
Electrolytes : Na K
Every visit till stidy
BNP
Every visit
SCr
HTN BP HR
Every day DM
Sugar level
Dyslipidemia
Weight
HDL, LDL,TG
Daily
Once a week
Atrial Fib
everyday
COPD
Breathing ,cough

31. PCP Goals Monitoring parameters Freq Achievements of outcomes comments
Valsartan :
Monitor potassium and serum creatinine
Every visit
Furosemide :
monitor electrolyte(Na/K ,hyperuricemia , nephrotoxicity & autotoxicity
Metoprolol succinate:
BP, HR baseline ECG
Daily
1ce amonth

32. Q&A

33. Dalya & Lina
Therapy Lab (Tuesday)