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 Hypertension/Heart Failure Discussion Essays.
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 Hypertension/Heart Failure Discussion Essays. 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 Hypertension/Heart Failure Discussion Essays.
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 Hypertension/Heart Failure Discussion Essays