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

I would classify this particular patient in New York Heart Association (NYHA) functional classification as class II heart failure and as stage C in American College of Cardiology/American Heart Association (ACC/AHA) staging criteria.  I see this woman being functional and mildly limited since she can walk 2-3 blocks before having trouble breathing.  Chisolm-Burns et al. (2019) describes the treatment goal for Heart Failure (HF) as “preventing the onset of clinical symptoms or reducing symptoms, preventing or reducing hospitalizations, slowing progression of the disease, improving quality of life, and prolonging survival”  (Chisolm-Burns, et al., 2019, p. 76).  Treatment goals for ACC/AHA stage 3 include symptom control through the addition of ancillary therapies and morbidity reduction.

This patient’s blood pressure is higher than recommended for those with HF.  With the hypertension and edema, I would increase the patient’s HCTZ to 25mg daily to start.  I would ask the patient to notify the office if her edema was unimproved, then I would increase to 50mg daily.  Sinha, (2020), indicates Verapamil should not be used in patients whose hearts do not properly pump blood or those having severe congestive heart failure.  I would add an ace inhibitor such as lisinopril or captopril to treat the high blood pressure and heart failure.  I would closely monitor the ibuprophen use as Ogbru (2019) indicates nonsteroidal antiinflamatories may increase salt and fluid retention thereby decreasing the effectiveness of the ACE inhibitor Hypertension/Heart Failure Discussion Essays.

Monitoring parameters I would recommend would be blood pressure, maintaining it, according to Chisolm-Burns et al. (2019) at 130/80 or less.  I would also monitor the lower extremety edema and suggest the patient weight herself daily and to notify the office should she gain 3 pounds or more from one day to the next.  I would also ask the patient to self monitor her activity level and if there are changes in tolerance, SOB with exertion or at rest, or increased SOB affecting sleep.

Non-pharmacological recommendations I would suggest and supported by Chisolm-Burns (2019) would be smoking cessation if the patient is a smoker, salt and fluid restriction, encourage regular exercise, and receipt of flu and pneumonia vaccinations.  I would also educate the patient not to use salt substitute because of the potassium and the potential for the ACE inhibitor to increase potassium levels.  Also, I would recommend gauging how much this patient can understand and handle at one time and her willingness and readiness for change.  It may be that education and non-pharmacological interventions be geared to what is absolutely most important as the patient may only be able to institute one thing at this time Hypertension/Heart Failure Discussion Essays.

References

Chisolm-Burns, M. A., S, Schwinghammer, T. L., Malone, P. M., Kolesar, J. M., Lee, J. M., & Bookstaver, P. B. (2019). Pharmacotherapy Principles & Practice (Fifth ed.). McGrraw-Hill Education.