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HEART FAILURE:SYSTOLIC AND
DIASTOLIC DYSFUNCTIONBy: Dale Faith O. Dumalagan
Marc Edrial
Heart Failure 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
HEART FAILURE: SYSTOLIC DYSFUNCTION
MARC EDRIAL
SYSTOLIC DYSFUNCTION• DECREASED CONTRACTILITY- The strength for
ventricular contraction is attenuated and inadequate for creating adequate stroke volume, resulting to inadequate cardiac output.
Can be caused by:
• Ischemic Heart Disease (Coronary Atherosclerosis)• Hypertension• Dilated Cardiomyopathy
IHF to Systolic dysfunction
• IHF is plaque build-up• Less oxygenated blood to
cardiac muscles= Weaker cardiac muscles=Weaker contractions!
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!)
Dilated Cardiomyopathy to Systolic Dysfunction
• Heart chamber grows big= less muscle (Thinner cardiac muscles) causing less pumping out of blood
=Heart failure!
…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
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
Drugs needed • Ace inhibitors to dilate
blood vessels• Diuretics to reduce fluid
retention
HEART FAILURE:DIASTOLIC
DYSFUNCTION
DALE FAITH O. DUMALAGAN
Ejection Fraction
- is a measurement of the percentage of blood leaving your heart each time it contracts.
- normal values are 50-75%
• FormulaSV= EDV - ESVEF= SV / EDV
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
CASE STUDY:SYSTOLIC DYSFUNCTION
MARC EDRIAL
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.
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.”
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.
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.
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
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
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.”
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
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
PHYSICAL EXAMINATION• GenThe patient is sitting up on the gurney in the ED in moderate distress.• VSBP 150/95 P 100–120RR 22T 35°CWt 103 kg (usual weight 93 kg)Ht 5'11''
PHYSICAL EXAMINATION
• HEENTPERRLA, 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/ThoraxRespirations are even. There are fine crackles in both lung fields
PHYSICAL EXAMINATION
• SkinPale and diaphoretic, no unusual lesions• HeartRegular 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.• AbdSoft, NT/ND, (+) HJR, liver and spleen slightly enlarged, no masses, hypoactive bowel sounds
PHYSICAL EXAMINATION
• Genit/RectGuaiac (–), genital examination not performed• Ext3+ pitting pedal edema bilaterally; radial and pedal pulses are of poor intensity bilaterally; grip strength greater on left than on right• NeuroA & O × 3, CNs intact. Some sensory loss in both LE below the knee. DTR 1+
PHYSICAL EXAMINATION
• ECGSinus tachycardia rate of 112, QRS 0.08. Diffuse non specific ST-T wave changes. Low voltage.• Chest X-RayPA and lateral show evidence of congestive failure with cardiomegaly, interstitial edema, and some early alveolar edema. There is a small right pleural effusion.
• Note presence of severe Left Ventricular Dilation
• Note presence of Pulmonary effusion, edema
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/dLTwo hours after eating
Remarks
Normal
Normal
Normal
Normal
Normal
High
Normal
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
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
ASSESMENT
• Diabetic patient with new-onset congestive heart failure
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.
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
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.
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.
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 hypercholesterolemiaThe therapeutic goals for CHF are to improve quality of life, relieve or reduce symptoms, prevent or minimize hospitalizations, slow disease progression, and prolong survival.
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
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
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
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.
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
• 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.
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
• 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
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.
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.
Follow-up questions
• 3. Outline a therapeutic plan for transitioning this patient from carvedilol immediate release to the controlled release product
• CarvedilolStart at 3.125 mg bidSlowly 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.
Heart Failure: Diastolic Dysfunction
By: Dale Faith O. Dumalagan
Be Still My Racing Heart.............................. Level IIIJon D. Horton, PharmD
Patient ProfileName: Nina OrendorffAge: 83 years oldSex: Female
Chief Complaint
“I can't catch my breath”
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
Past Medical History Type 2 DM x 5 years, diet controlled HTN x 40 years
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
Social History Retired schoolteacher who lives at
home alone Reports enjoying a cocktail while
playing cards with friends
Current Medical TreatmentMEDICATION DOSE
Minoxidil 10 mg po bid
MinoxidilIs 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.
Allergy No known drug allergy
Review of SystemsGeneral
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
Resp Shortness of breath New cough but not productive No recent respiratory
infectionsGI
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
Physical ExaminationGeneral
Patient is sitting up on the gurney in moderate distressVital Signs
BP : 150/100 120/80 P : 100 - 130 (regular)RR : 28 fast
Temp: 35℃Wt : 73 kg (usual 65 kg)Ht : 5'3”
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
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
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
Laboratory FindingsRESULTS 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/dLTwo 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
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
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
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
Electrocardiogram Sinus tachycardia rate of 112 60–100 bpm QRS 0.08 Diffuse nonspecific ST-T wave changes Low voltage
CXRPA and lateral views show evidence of interstitial edema and some early alveolar edema
AssessmentDiet-controlled patient with Type 2 DM and new-onset
congestive heart failure
Clinical CourseThe 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
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 hypertension3. 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 & ARBs3. Concomitant use of an
adequate diuretic is required; high ceiling (loop) diuretic is almost always required; Monitor fluid and electrolyte balance and body weight
DRUG USE PROBLEM MANAGEMENTMinoxidil
10 mg po bid4. Angina may worsen or appear for the first time during minoxidil treatment5. Pulmonary edema
4. Conduct ECG and monitor
5. Diuretic treatment alone, or in combination with restricted salt intake, will usually minimize fluid retention
1.b) What signs, symptoms, and other information indicate the presence and severity of the patient's heart failure?
1. Elevated HR - 110-120bpm2. Worse dyspnea on exertion over two weeks, orthopenia , & paroxysmal nocturnal dyspnea3. SOB, persist even at rest4. Type II DM5. HTN x40yrs6. Only one medication, Minoxidil (not enough)7. Weight gain8. Peripheral edema9. Elevated BP 150/100 10. Fast Respiratory Rate11. (+) JVD at 30°(6cm) Normal: 4cm or less12. Lungs: Crackles on both lungs but no cough is not productive13. Heart: S3 appreciated at apex in lateral position, PMI displaced laterally & difficult to discern14. ABD: (+) HJR, Liver and spleen slightly enlarged15. Detection of Troponin I ( slight elevation)
1.c) What are the classification and staging of this patient's heart failure upon presentation?
Stage C
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
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
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
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
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
Pharmacological Goals:For HTN-
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
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
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).
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.
1. Carvedilol 3.125 mg twice daily (initially )25 mg twice daily (target dose)
2. 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.
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 Support1. Intraaortic Balloon Pump2. Ventricular Assist Device
Surgical therapy
Outcome Evaluation
Intraaortic Balloon Pumpemployes 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
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
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
Shortage of donor hearts has prompted developent of new surgical techniques which have resulted in variable degrees of symptomatic improvement1. Ventricular aneurysm
resection
2. Mitral valve repair
3. Myocardial cell transplantation
Clinical CourseOver 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
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
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
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
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
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
