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Pharmacotherapy Casebook: A Patient-Focused Approach, 10e

Chapter 15: Heart Failure with Reduced Ejection Fraction: Cross My Heart and Hope to Live Level

III Julia M. Koehler; Alison M. Walton

FIGURE 15-1.

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LEARNING OBJECTIVES

A�er completing this case study, the reader should be able to:

Recognize the signs and symptoms of heart failure.

Develop a pharmacotherapeutic plan for treatment of heart failure with reduced ejection fraction (HFrEF).

Outline a monitoring plan for heart failure that includes both clinical and laboratory parameters.

PATIENT PRESENTATION

Chief Complaint

“I’ve been more short of breath lately. I can’t seem to walk as far as I used to, and either my feet aregrowing or my shoes are shrinking!”

HPI

Rosemary Quincy is a 68-year-old African-American female who presents to her family medicine physicianfor evaluation of her shortness of breath and increased swelling in her lower extremities. She reports thather shortness of breath has been gradually increasing over the past 4 days. She has noticed that hershortness of breath is particularly worse when she is lying in bed at night, and she has to prop her head upwith three pillows in order to sleep. She also reports exertional dyspnea that is usual for her, but especiallyworse over the past couple of days.

PMH

Hypertension × 20 years

CHD with history of MI in 2005 (PCI performed and bare metal stents placed in LAD and RCA)

Heart failure (NYHA FC III)

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Type 2 DM × 25 years

Atrial fibrillation

COPD (GOLD 3, Group D)

CKD (Stage 4)

FH

Father died of lung cancer at age 71, mother died of MI at age 73.

SH

Reports occasional alcohol intake. States she has been trying to follow her low-cholesterol and low-sodiumdiet. Former smoker (35 pack-year history; quit approximately 10 years ago).

Meds

Valsartan 160 mg PO BID

Furosemide 40 mg PO BID

Warfarin 2.5 mg PO once daily

Carvedilol 3.125 mg PO BID

Pioglitazone 30 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, two inhalations by mouth q 4–6 hours PRN shortness of breath

Tiotropium DPI 18 mcg, one inhalation by mouth daily

Fluticasone/salmeterol DPI 250 mcg/50 mcg, one inhalation by mouth BID

All

Lisinopril (cough).

ROS

Approximate 7-kg weight gain over the past week. No fever or chills. Denies any recent chest pain,palpitations, or dizziness. Reports worsening shortness of breath with exertion and three-pillow orthopnea.

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Describes a chronic, dry (nonproductive), hacking cough, which she describes as usual without recentworsening. No abdominal pain, nausea, constipation, or change in bowel habits. Denies joint pain orweakness.

Physical Examination

Gen

African-American female in moderate respiratory distress

VS

BP 134/76 (sitting; repeat 138/78), HR 65 (irreg irreg), RR 24, T 37°C, O2 sat 90% RA, Ht 5′5″, Wt 79 kg (Wt 1

week ago: 72 kg)

Skin

Color pale and diaphoretic; no unusual lesions noted

HEENT

PERRLA; lips mildly cyanotic; dentures

Neck

(+) JVD at 30° (7 cm); no lymphadenopathy or thyromegaly

Lungs/Thorax

Crackles bilaterally, 2/3 of the way up; no expiratory wheezing

Heart

Irregularly irregular; (+) S3; displaced PMI

Abd

So�, mildly tender, nondistended; (+) HJR; no masses, mild hepatosplenomegaly; normal BS

Genit/Rect

Guaiac (–), genital examination not performed

MS/Ext

3+ pitting pedal edema bilaterally; radial and pedal pulses are of poor intensity bilaterally

Neuro

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A & O × 3, CNs intact. No motor deficits

Labs

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Na 131 mEq/L Hgb 13 g/dL Mg 1.9 mEq/L INR 2.3

K 3.5 mEq/L Hct 40% Ca 9.3 mg/dL A1C

6.1%

Cl 99 mEq/L Plt 192 × 103/mm3 Phos 4.3

mg/dL

CO2 28 mEq/L WBC 9.1 ×

103/mm3

AST 34 IU/L

BUN 32 mg/dL ALT 27 IU/L

SCr 2.3 mg/dL (baseline SCr 2.1 mg/dL)

Glucose 124 mg/dL

BNP 776 pg/mL (BNP drawn 2 months prior: 474

pg/mL)

ECG

Atrial fibrillation, LVH.

Chest X-Ray

PA and lateral views (Fig. 15-1) show evidence of congestive failure with cardiomegaly, interstitial edema,and some early alveolar edema. There is a small right pleural e�usion.

FIGURE 15-1.

A. PA CXR demonstrates increased vascular markings representative of interstitial edema, with some earlyalveolar edema. The arrow points out fluid lying in the fissure of the right lung. Note the presence ofcardiomegaly. B. Lateral view of CXR. Arrow points out the presence of pulmonary e�usion.

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No evidence of infiltrates; evidence of pulmonary edema suggestive of congestive heart failure; enlargedcardiac silhouette.

Echocardiogram

LVH, reduced global le� ventricular systolic function, estimated EF 20%; evidence of impaired ventricularrelaxation, Stage 1 diastolic dysfunction.

Assessment

Admit to hospital for acute exacerbation of heart failure

QUESTIONS

Problem Identification

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1.a. Create a list of this patient’s drug-related problems.

1.b. What signs, symptoms, and other information indicate the presence and type of heart failure in thispatient?

1.c. What is the classification and staging of chronic heart failure for this patient?

1.d. Could any of this patient’s problems have been caused by drug therapy?

Desired Outcome

2. What are the goals for the pharmacologic management of heart failure in this patient?

Therapeutic Alternatives

3.a. What diuretic therapy should be recommended for this patient initially for acute treatment of her heartfailure exacerbation?

3.b. How should this patient’s pharmacotherapy be adjusted for chronic management of her heart failure?

3.c. What nonpharmacologic therapy should be recommended for this patient with respect to her heartfailure?

Optimal Plan

4. What drugs, doses, schedules, and duration are best suited for the management of this patient?

Outcome Evaluation

5. What clinical and laboratory parameters are needed to evaluate the therapy for achievement of thedesired therapeutic outcome and to detect and prevent adverse events?

Patient Education

6. What information should be provided to the patient about the medications used to treat her heartfailure?

SELF-STUDY ASSIGNMENTS

1. Develop a table illustrating the recommended target doses for ACE inhibitors, angiotensin II receptorblockers, and β-blockers in patients with heart failure with reduced EF.

2. Research the topic of diuretic resistance, and write a report describing the phenomenon and methodsused to overcome it.

3. Review the guidelines and evidence describing the role of routine BNP monitoring in patients withheart failure.

CLINICAL PEARL

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The presence of pitting edema is associated with a substantial increase in body weight; it typically takes aweight gain of 10 lb to result in the development of pitting edema.

REFERENCES

Nesto  RW, Bell  D, Bonow  RO,  et al. AHA/ADA consensus statement for thiazolidinedione use, fluidretention, and congestive heart failure. Circulation 2003;108:2941–2948.  [PubMed: 14662691]

Yancy  CW, Jessup  M, Bozkurt  B,  et al. 2013 ACCF/AHA guideline for the management of heart failure: areport of the American College of Cardiology Foundation/American Heart Association Task Force onPractice Guidelines. J Am Coll Cardiol 2013;62:e147–e239. doi: 10.1016/j.jacc.2013.05.019.  [PubMed:23747642]

Cohn  JN, Tognoni  G; Valsartan Heart Failure Trial Investigators. A randomized trial of the angiotensin-receptor blocker valsartan in chronic heart failure. N Engl J Med 2001;345:1667–1675.  [PubMed: 11759645]

Mentz  RJ, Wojdyla  D, Fiuzat  M, Chiswell  K, Fonarow  GC, O’Connor  CM. Association of beta-blocker useand selectivity with outcomes in patients with heart failure and chronic obstructive pulmonary disease(from OPTIMIZE-HF). Am J Cardiol 2013;111:582–587.  [PubMed: 23200803]

Pitt  B, Zannad  F, Remme  WJ. The e�ect of spironolactone on morbidity and mortality in patients withsevere heart failure. Randomized Aldactone Evaluation Study Investigators. N Engl J Med 1999;341:709–717.  [PubMed: 10471456]

Pitt  B, Remme  W, Zannad  F,  et al. Eplerenone, a selective aldosterone blocker, in patients with le�ventricular dysfunction a�er myocardial infarction. N Engl J Med 2003;348:1309–1321.  [PubMed:12668699]

Zannad  F, McMurray  JJV, Krum  H,  et al.; for the EMPHASIS-HF Study Group. Eplerenone in patients withsystolic heart failure and mild symptoms. N Engl J Med 2011;364:11–21.  [PubMed: 21073363]

Butler  J, Ezekowitz  JA, Collins  JP,  et al. Update on aldosterone antagonists use in heart failure withreduced le� ventricular ejection fraction. Heart Failure Society of America Guidelines Committee. J CardFail 2012;18:265–281.  [PubMed: 22464767]

Taylor  AL, Ziesche  S, Yancy  C,  et al.; for the African-American Heart Failure Trial Investigators.Combination of isosorbide dinitrate and hydralazine in blacks with heart failure. N Engl J Med2004;351:2049–2057.  [PubMed: 15533851]

Swedberg  K, Komajda  M, Bohm  M,  et al. Ivabradine and outcomes in chronic heart failure (SHIFT): arandomised placebo-controlled study. Lancet 2010;367:875–885.

Yancy  CW, Jessup  M, Bozkurt  B,  et al. 2016 ACC/AHA/HFSA Focused Update on New PharmacologicalTherapy for Heart Failure: An Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure:A Report of the American College of Cardiology Foundation/American Heart Association Task Force on

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12. 

13. 

Clinical Practice Guidelines and the Heart Failure Society of America. Circulation 2016;134.DOI:10.1161/CIR0000000000000435.

McMurray  JV, Packer  M, Desai  AS,  et al. Angiotensin-neprilysin inhibition versus enalapril in heartfailure. N Engl J Med 2014;371:993–1004.  [PubMed: 25176015]

Moe  GW, Ezekowitz  JA, O’Meara  E,  et al. The 2014 Canadian Cardiovascular Society Heart FailureManagement Guidelines Focus Update: anemia, biomarkers and recent therapeutic trial implications. CanJ Cardiol 2015;15:3–16.

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