A 50yo African American woman presents to clinic feeling tired for the last 3 months. She also has trouble breathing when walking 2-3 blocks. She sleeps on 2 pillows at night to help with her breathing. PMH: HTN, arthritis. Physical exam: edema present in both feet. Medications: HCTZ 12.5mg daily, verapamil SA 120 mg daily, ibuprofen 200 mg BID for arthritis in knee. Vitals: height 5'2", 63kg, BP 134/84, HR 78, EF 30% per echocardiogram. Her labs are normal including a creatinine of 1.1. She denies chest pain or palpitations. Her EKG reveals normal sinus rhythm with no evidence of ischemia or recent acute coronary syndrome. How would you classify her heart failure? What changes (modifications, additions, deletions) to her medications do you recommend that will: Improve her symptoms? Impact long term outcomes? What monitoring parameters do you recommend? What non-pharmacologic recommendations do you have?

A 50yo African American woman presents to clinic feeling tired for the last 3 months. She also has trouble breathing when walking 2-3 blocks. She sleeps on 2 pillows at night to help with her breathing. PMH: HTN, arthritis. Physical exam: edema present in both feet. Medications: HCTZ 12.5mg daily, verapamil SA 120 mg daily, ibuprofen 200 mg BID for arthritis in knee. Vitals: height 5'2", 63kg, BP 134/84, HR 78, EF 30% per echocardiogram. Her labs are normal including a creatinine of 1.1. She denies chest pain or palpitations. Her EKG reveals normal sinus rhythm with no evidence of ischemia or recent acute coronary syndrome. How would you classify her heart failure? What changes (modifications, additions, deletions) to her medications do you recommend that will: Improve her symptoms? Impact long term outcomes? What monitoring parameters do you recommend? What non-pharmacologic recommendations do you have?

1 Module 10 Heart Failure According to the American Heart Association, heart failure is classified according to the severity of the symptoms that the patient is experiencing (Classes of Heart Failure, n.d.). In the case of our 50-year-old African American woman who is experiencing dyspnea with exertion and having breathing problems at night along with her dependent edema and moderately abnormal ejection fraction I would classify her heart failure as functional capacity III, objective assessment C (Classes of Heart Failure, n.d.). Heart failure is usually treated with ACE inhibitors, beta blockers and diuretics. “According to the new recommendations, a therapeutic regimen of an ACE inhibitor or ARB or ARNI along with a beta blocker and an aldosterone antagonist is the new recommended therapy for patients with chronic symptomatic heart failure with reduced ejection fraction. ARNIs should replace ACE inhibitors (or ARBs) when stable patients with mild-to-moderate heart failure on these therapies have an adequate blood pressure and are otherwise tolerating standard therapies well. ARNIs, however, should not be used with an ACE inhibitor and should not be used by patients with a history of angioedema” (Acc/aha/hfsa Guideline for Management of Heart Failure Update, n.d.). The purpose of these medications is to relax blood vessels, reduce (biological) stress and improve the function of the heart (Acc/aha/hfsa Guideline for Management of Heart Failure Update, n.d.). Lifestyle modifications would include a reduction in weight. Currently our patient is in the overweight class according to the BMI chart. Her healthy normal weight should range from 101lbs-139lbs. Being diagnosed with heart failure she should be tracking her weight daily and reporting a gain of 3 pounds or more. Maintaining a healthy diet of fish, poultry, and vegetables will help with weight management. Education on limiting saturated fat, trans fat, cholesterol, This study source was downloaded by 100000882596535 from CourseHero.com on 03-18-2024 00:54:49 GMT -05:00 https://www.coursehero.com/file/178856164/ADV-Pharm-Module-10-HFdocx/ 2 sodium, red meat, alcohol, sweets and sugar-sweetened beverages should be included in the dietary plan. All patients should adhere to a regular and safe exercise regimen. In addition to tracking daily weights this patient should also monitor blood pressure since she is already diagnosed with HTN. In the case of the 79-year-old female African American woman the WHO recommends “the use of drugs from any of the following three classes of pharmacological antihypertensive medications as an initial treatment: thiazide and thiazide-like agents; angiotensin-converting enzyme inhibitors (ACEs)/angiotensin-receptor blockers (ARBs); long-acting dihydropyridine calcium channel blockers (CCBs)” (Weltgesundheitsorganisation & Organization, 2021). The WHO states that long-acting anti-hypertensives are preferred and that CCBs should be used in patients over 65 and of African American descent. This patient is already prescribed felodipine which is a CCB and benazepril which is an ACE. We do not know if this patient is compliant with her current medication regimen. There are single pill combination therapies that could be prescribed if medication compliance was an issue. However, “most individuals with HTN will eventually require two or more antihypertensive agents to achieve BP control and the combination of two agents from complementary classes yields greater BP-reduction efficacy” (Weltgesundheitsorganisation & Organization, 2021). At presentation this patient’s blood pressure is not meeting the current WHO standards of <130mm Hg. This patient’s TIA would be considered a cardiovascular risk factor even though it is classified as cerebrovascular disease. “Cardiovascular disease, also known as heart disease, refers to the following 4 entities: coronary artery disease (CAD) which is also referred to as coronary heart disease (CHD), cerebrovascular disease, peripheral artery disease (PAD), and aortic atherosclerosis” (Olvera Lopez E, Ballard BD, Jan A. Cardiovascular Disease). This study source was downloaded by 100000882596535 from CourseHero.com on 03-18-2024 00:54:49 GMT -05:00 https://www.coursehero.com/file/178856164/ADV-Pharm-Module-10-HFdocx/ 3 This patient is currently prescribed febuxostat to help reduce the production of uric acid in the body, but it could cause serious or fatal heart problems. If tolerated she should be switched to allopurinol. This patient should be followed closely every 3-6 months to monitor blood pressure and possible needs for adjustments to medications. References Acc/aha/hfsa guideline for management of heart failure update. (n.d.). https://hfsa.org/accahahfsa-guideline-management-heart-failure-update Classes of heart failure. (n.d.). www.heart.org. https://www.heart.org/en/health-topics/heartfailure/what-is-heart-failure/classes-