Download CH15 Page 1-6

15-1
HEART FAILURE WITH
REDUCED EJECTION FRACTION
Cross My Heart and Hope to Live. . . . . . . . . . . . . . . Level III
Alison M. Walton, PharmD, BCPS
1.b. What signs, symptoms, and other information indicate the
presence and type of HF in this patient?
• Shortness of breath: exertional dyspnea and orthopnea
(three-pillow)
• Peripheral edema (3+ pitting)
• Diminished peripheral pulses
• JVD
• HJR
CASE SUMMARY
A 68-year-old African-American female with past medical history
significant for hypertension, CHD, MI, type 2 DM, atrial fibrillation, COPD, CKD, and heart failure (HF) presents to her primary
care physician complaining of exertional dyspnea, orthopnea, and
lower extremity swelling. On exam, the patient is found to have
pulmonary edema and pitting edema of the lower extremities, and
elevated B-type natriuretic peptide (BNP) from baseline. The patient
is diagnosed with an acute exacerbation of HF and is admitted to
the hospital for intravenous (IV) diuretic therapy and adjustment
of her chronic medications for systolic dysfunction. The patient has
been taking medications for management of her type 2 DM that
may have a negative impact on her HF. Additionally, the presence
of comorbid COPD and hypertension in this patient warrants consideration in light of her HF regimen.
QUESTIONS
Problem Identification
1.a. Create a list of this patient’s drug-related problems.
Drug-related problems requiring attention at this time:
• Acute exacerbation of chronic HF requiring drugs and other
treatment.
• Pioglitazone may worsen symptoms of HF and is contraindicated in patients with New York Heart Association (NYHA)
functional class III or IV HF.1
Chronic, stable drug-related problems requiring no intervention at
this time:
• COPD: controlled; no signs of wheezing; shortness of breath
due to HF, as indicated by physical exam findings and BNP. Of
note, the patient is receiving carvedilol, which is a nonselective
β-blocker that may have the potential to worsen the patient’s
COPD. A β1-selective agent may be a more appropriate choice
for this patient.
• Hypertension in the presence of HF, CHD, and diabetes with
blood pressure (BP) currently at goal.
• Atrial fibrillation: rate controlled; addition of digoxin may
be warranted if rate becomes uncontrolled despite current
therapy, or if further control of HF symptoms is necessary.
• Type 2 DM: controlled; A1C indicates average blood sugar
running in the 130s.
• PND
• Hepatosplenomegaly
• LVH
• Cardiomegaly
• S3 gallop
• Rales/pulmonary edema
• Seven-kilogram weight gain
• Elevated BNP:
✓BNP is a cardiac neurohormone specifically secreted from
the ventricles in response to volume expansion and pressure
overload. BNP levels are elevated in patients with left ventricular dysfunction and have been demonstrated to correlate with the NYHA classification, as well as prognosis. They
assist clinicians in distinguishing acute congestion associated with HF from other causes of dyspnea, such as COPD,
asthma, or pneumonia, particularly when the presenting
symptoms are nonspecific, and physical findings are not
sensitive enough to use as a basis for an accurate diagnosis.
In this particular case, the elevated BNP levels suggest that
the patient’s dyspnea is possibly related to volume overload
and LV dysfunction. BNP measurement is a sensitive and
specific test to diagnose HF in the emergency department or
urgent care setting.
• Displaced PMI.
• Based on the information that is from the cardiac ECHO,
such as the documented ejection fraction (EF) of 20% and
findings suggestive of impaired ventricular relaxation, this
patient should be considered to have both systolic dysfunction
and diastolic dysfunction. (See also Question 1.c.) In any case,
the pharmacotherapy for this patient should be selected on
the basis of left ventricular systolic dysfunction (LVSD) as the
underlying disease.
1.c. What is the classification and staging of chronic HF for this
patient?
The American College of Cardiology Foundation/American Heart
Association (ACCF/AHA) considers EF important in the classification of HF patients. It is preferable to use the term HF with
reduced EF (HFrEF) for patients with a clinical diagnosis of HF and
EF ≤40%. The ACCF/AHA stages of HF emphasize the development and progression of disease, whereas the NYHA Functional
Classification (FC) focuses on exercise capacity and the symptomatic status of the disease. Both the ACCF/AHA stages of HF and the
NYHA FC provide meaningful and complementary information
about the presence and severity of HF.2
Copyright © 2017 by McGraw-Hill Education. All rights reserved.
Heart Failure with Reduced Ejection Fraction
Julia M. Koehler, PharmD, FCCP
• CKD: stable; SCr slightly increased above baseline on presentation but likely secondary to HF exacerbation leading to
decreased renal perfusion.
CHAPTER 15
15
• CHD: stable.
15-2
SECTION 2
ACCF/AHA Stages of HF
NYHA Functional Classification
A: At high risk for HF, but
without structural heart
disease or symptoms of HF
B: Structural heart disease, but
without signs or symptoms
of HF
C: Structural heart disease
with prior or current
symptoms of HF
None
Cardiovascular Disorders
D: Refractory HF requiring
specialized interventions
I: No limitation of physical activity. Ordinary
physical activity does not cause symptoms
of HF
I: No limitation of physical activity. Ordinary
physical activity does not cause symptoms
of HF
II: Slight limitation of physical activity.
Comfortable at rest, but ordinary physical
activity results in symptoms of HF
III: Marked limitation of physical activity.
Comfortable at rest, but less than ordinary
physical activity causes symptoms of HF
IV: Unable to carry on any physical activity
without symptoms of HF, or symptoms of
HF at rest
• Based on the above criteria, this patient would be considered
to have HFrEF and classified as ACCF/AHA Stage C, NYHA
FC III HF.
1.d.Could any of this patient’s problems have been caused by
drug therapy?
• The patient is currently taking pioglitazone, which may have
contributed to volume overload. Post-marketing experience
has demonstrated an increased incidence of peripheral edema
in patients with or without HF, in addition to reports of
pulmonary edema and pleural effusions. Peripheral edema
is reported in approximately 4.8% of patients receiving pioglitazone monotherapy compared with 1.2% of patients taking
placebo. When pioglitazone is combined with sulfonylureas,
edema is noted in 7.5% of patients compared with 2.1% of
patients on sulfonylureas alone. According to a consensus
statement from the AHA and the American Diabetes Association (ADA), thiazolidinediones should not be used in patients
with symptomatic or moderate-to-severe HF (ie, NYHA FC III
and IV).1
Desired Outcome
2.What are the goals for the pharmacologic management of HF
in this patient?
• Resolve the current exacerbation of HF and achieve euvolemic
status.
• Reduce symptoms and improve functional capacity and quality of life.
• Reduce hospitalizations and acute care visits.
• Slow progression of HF and prolong survival.
Therapeutic Alternatives
3.a.What diuretic therapy should be recommended for this
patient initially for acute treatment of her HF exacerbation?
• The patient’s home furosemide regimen is 40 mg orally given
BID. For a HF exacerbation, enhancing the bioavailability of
this drug is essential. Thus, furosemide must be given IV.
• The equivalent IV dose to the patient’s home regimen would be
20 mg IV BID; however, a more aggressive approach would be
to essentially double the dose of furosemide in addition to IV
administration (ie, administer at least 40 mg IV BID). According to the 2013 ACCF/AHA HF guidelines, the management
of a hospitalized patient experiencing an acute exacerbation
Copyright © 2017 by McGraw-Hill Education. All rights reserved.
of HF should include IV loop diuretic therapy that equals or
exceeds the chronic oral daily dose and should be given either
as boluses or by continuous infusion.2
• Monitoring of diuretic therapy for this patient should include
daily potassium, weights, ins and outs (I&Os), serum electrolytes, BUN, and SCr. While monitoring of serial BNPs has
been done for some patients during hospitalization for acute
HF exacerbation, this practice is not recommended according
to the 2013 ACCF/AHA HF guidelines.2
3.b. How should this patient’s pharmacotherapy be adjusted for
chronic management of her HF?
• The patient’s angiotensin II receptor blocker (ARB) should be
maintained at the current dose, as drugs within this class (as
well as ACE inhibitors) have been shown to reduce morbidity
and mortality in HFrEF. The Val-HeFT trial showed a significant reduction in the combined end point of mortality and
morbidity with valsartan compared with placebo in patients
with NYHA FC II, III, or IV (there was no difference in mortality alone, however).3 Based on Val-HeFT, the “target dose”
for valsartan is 160 mg po BID.3 In this case, the valsartan dose
is at target and is at the maximum recommended daily dose of
320 mg daily; therefore, upward titration of the valsartan dose
is not necessary.
• Loop diuretics, such as furosemide and torsemide, reduce morbidity in HF by reducing excess fluid overload and improving
symptoms of congestion. In this case, the patient’s furosemide
dose may need to be adjusted on discharge, given that the
patient’s home regimen of furosemide failed to help the patient
maintain a euvolemic status.
✓The patient’s adherence to her diuretic regimen and her lowsodium diet should first be considered, before an appropriate
dose adjustment can be made.
✓Assuming the patient has been adherent to her diuretic regimen, an increase in furosemide dosage on discharge may be
warranted. There is no need to consider adding metolazone
(a thiazide-like diuretic), or switching to torsemide (a loop
diuretic with more predictable oral bioavailability), at this
time.
• β-Blockers, such as metoprolol succinate, carvedilol, and bisoprolol, are also indicated in the management of chronic HF, as
these agents, when added to either ACE inhibitors or ARBs,
have also been demonstrated to further reduce morbidity and
mortality.2
✓In this case, the patient’s β-blocker dose is not at target.
The dose of the β-blocker should be titrated upward to the
recommended target dose (ie, that which has been shown
to reduce morbidity and mortality in clinical trials), as
tolerated. Upward dose titration of a β-blocker during an
acute exacerbation of HF is not recommended. Once the
patient has been diuresed and the HF exacerbation has been
resolved (ie, the patient is considered “euvolemic”), the dose
of the β-blocker can be increased (ie, doubled). With each
dose increase, the patient should be carefully monitored for
fluid retention, symptoms of worsening HF, fatigue, bradycardia, heart block, or hypotension.
✓ In addition, consideration may need to be given to switching
the patient’s β-blocker to a β1-selective agent, given her concomitant COPD. A recently published retrospective analysis
evaluating impact of β-blocker selectivity on outcomes in
patients with HF and concomitant COPD found no evidence
to suggest that noncardioselective β-blockers worsened
outcomes (60-day mortality and rehospitalization) for such
15-3
✓ In the RALES trial, treatment with spironolactone in patients
with NYHA FC III or IV was associated with a 34% risk
reduction in mortality and a 30% reduction in hospitalization rates.5
✓In the EPHESUS trial, 6632 post-MI patients with LVSD
(EF <35%) already receiving optimal medical therapy (ACE
inhibitors or ARBs, diuretics, β-blockers, and coronary
reperfusion therapy) were randomized to receive either
eplerenone or placebo. Treatment with eplerenone resulted
in a significant reduction in both morbidity and mortality.6
In the EMPHASIS-HF trial, patients with LVSD and mild
symptoms who received eplerenone (in addition to optimal
medical treatment with ACE inhibitors or ARBs, β-blockers,
and diuretics) benefited from a significant reduction in morbidity and all-cause mortality.7
✓ Based on the findings of the EMPHASIS-HF trial, the Heart
Failure Society of America (HFSA) issued an update to
their treatment recommendations stating that aldosterone
antagonists (unless contraindicated) should be added to
standard therapy for HF in patients with LVSD and NYHA
FC II–IV. For patients in NYHA FC II, the HFSA further recommends that the indication for an aldosterone
antagonist include one additional high-risk factor, such as
age >55 years, QRS duration <130 milliseconds (if LVEF
31–35%), hospitalization due to HF within the previous
6 months, or elevated BNP.8 The 2013 ACCF/AHA HF
guidelines also updated their recommendations to include
the use of aldosterone antagonists in HF patients (EF ≤35%)
with NYHA FC II and history of prior cardiovascular hospitalization or elevated BNP levels.2
✓Given that the patient’s serum potassium in this case is
toward the low end of the normal range (and given the
patient’s history of MI) and current need to increase diuretic
therapy, consideration could be given to the addition of
an aldosterone antagonist to further reduce morbidity and
mortality. However, based on the 2013 ACCF/AHA HF
guidelines, it is recommended to ensure that SCr is less than
2 mg/dL in female patients without recent worsening of SCr
before starting an aldosterone antagonist (due to the risk for
hyperkalemia in such patients).2 Based on these criteria, it is
probably best to hold off on initiating an aldosterone antagonist for this patient at this time. If spironolactone or eplerenone were added, the patient should not be continued on a
daily potassium supplement. Obviously, potassium must be
monitored closely, and the recommendation is to check SCr
• Digoxin:
✓ The indications for digoxin include HF and atrial fibrillation.
✓Although this patient has atrial fibrillation, the patient’s
heart rate is controlled. As such, the addition of digoxin in
this case for further rate control in the setting of atrial fibrillation may not be warranted yet as long as the β-blocker
continues to provide adequate rate control.
✓ Although digoxin may reduce morbidity in HF by decreasing
hospitalizations and improving exercise tolerance, digoxin
does not reduce mortality in HF.
• Hydralazine plus isosorbide dinitrate (ISDN):
✓The 2013 ACCF/AHA guidelines recommend that the combination of hydralazine plus ISDN be added to standard
therapy (ie, optimal therapy with an ACE inhibitor or ARB,
β-blocker, and loop diuretics) for African-American patients
with NYHA FC III or IV HFrEF based on the findings of
A-HeFT.2,9 As described above, although this patient’s ARB
therapy is at the target dose, her β-blocker therapy has yet to
be maximized. Either hydralazine/ISDN could be added now
or the addition of this combination could be reconsidered as
an option once the β-blocker has been changed and titrated
to the recommended target dose. Consideration would need
to be given to the additional pill burden associated with this
regimen, as well as the potential added cost of this regimen
(if the combination product is chosen rather than individual
agents). Of course, hydralazine/ISDN should definitely be
added in the event that the patient develops an intolerance
or contraindication to ARB therapy.
• Ivabradine, a selective inhibitor of the If current at the sinoatrial node, has an indication to reduce the risk of hospitalization due to worsening heart failure in adult patients with
stable, symptomatic chronic HF with left ventricular EF of 35%
or less, who are in sinus rhythm with a resting heart rate of at
least 70 bpm, and who are receiving the maximum tolerated
dose of a β-blocker or have a contraindication to β-blocker use.
In the SHIFT trial, ivabradine was shown to reduce the risk of
hospitalization but not mortality when compared to placebo
in patients with NYHA FC II, III, or IV and a documented
EF of 35% or less who were already receiving optimized
therapy with β-blocker, ACE inhibitor or ARB, and aldosterone antagonist.10 Ivabradine received US approval in 2015,
and this medication is first in its class. The 2016 ACC/AHA/
HFSA guidelines for the management of heart failure state that
ivabradine can be beneficial to reduce HF hospitalizations for
patients with stable chronic HFrEF (NYHA FC II-III) who are
receiving standard HF therapy (including a beta-blocker at the
maximum tolerated dose) and who are in normal sinus rhythm
with a heart rate of 70 bpm or greater at rest.11 When evaluating a patient’s candidacy for ivabradine, consideration must be
given to the cost of this new agent, as well as contraindications,
which include abnormal heart rhythm and a resting heart rate
<60 bpm prior to treatment. In this case, the patient has atrial
fibrillation and is tolerating the prescribed β-blocker but not
yet receiving the recommended target dose for morbidity and
mortality benefit. Thus, it is best to avoid use of ivabradine and
focus on upward titration of β-blocker therapy.
• Sacubitril/valsartan, a combination ARB/neprilysin inhibitor, is indicated to reduce the risk of cardiovascular death
and hospitalization due to HF in patients with HFrEF. In the
PARADIGM-HF trial, sacubitril/valsartan, when compared to
Copyright © 2017 by McGraw-Hill Education. All rights reserved.
Heart Failure with Reduced Ejection Fraction
• Aldosterone antagonists, including spironolactone and eplerenone, have also been demonstrated to further reduce morbidity and mortality in HFrEF (NYHA FC II–IV) when added
to ACE inhibitors and diuretics, with or without digoxin.
Eplerenone, specifically, demonstrated a significant reduction
in morbidity and mortality when added to standard therapy
for patients with known HF following acute MI.
and potassium at baseline, after 3 days, after 1 week, monthly
for 3 months, and then every 6 months.
CHAPTER 15
patients. Spirometry was not performed to directly evaluate
the impact of β-blocker use on the patients’ pulmonary function, however.4 This patient is currently receiving carvedilol,
which is a nonselective α–β-blocker. A potentially appropriate recommendation would be to switch the patient’s dose to
a β1-selective agent, such as metoprolol XL, which has also
been shown to reduce morbidity and mortality in clinical
trials. It is important to also note that although a switch may
be made to a more β1-selective agent, tolerability of the target
dose may be a limiting factor, given the patient’s COPD and
potential loss of β1 selectivity at higher doses.
15-4
SECTION 2
Cardiovascular Disorders
enalapril, significantly reduced the risk for first hospitalization
for worsening HF, death from cardiovascular causes, and allcause mortality.12 Sacubitril/valsartan received US approval in
2015, and sacubitril is the first neprilysin inhibitor to become
available in the US. The 2016 ACC/AHA/HFSA heart failure
guidelines state that there is “moderate quality evidence” to
support the use of sacubitril/valsartan as an alternative to ACE
inhibitor or ARB therapy in conjunction with beta-blockers
and aldosterone antagonists in patients with chronic HFrEF.
In 2015, the Canadian Cardiovascular Society, in a focused
update that included recent HF studies, also acknowledged
that there is “high-quality evidence” for the use of sacubitril/
valsartan over ACE inhibitor or ARB therapy alone in patients
with mild-to-moderate HF with an EF of <40%, elevated
BNP, or hospitalizations for HF in the past 12 months while
on appropriate doses of guideline-directed medical therapy.13
When evaluating a patient’s candidacy for sacubitril/valsartan,
consideration must be given to the cost of this new agent,
as well as whether other morbidity- and mortality-reducing
therapies for HF are currently on board and optimally dosed.
In this case, the patient is currently receiving valsartan at the
target (maximum recommended) dose, but titration of the
patient’s β-blocker therapy toward the target dose recommended for morbidity and mortality reduction is warranted,
and this would be an appropriate next step prior to considering
a switch to sacubitril/valsartan.
• Warfarin therapy should be continued in this patient:
✓In light of the patient’s rate-controlled atrial fibrillation and
concomitant HF, anticoagulation therapy is indicated for
primary stroke prevention. The 2013 ACCF/AHA guidelines
recommend chronic anticoagulation therapy in patients
with chronic HF with permanent/persistent/paroxysmal
atrial fibrillation and an additional risk for cardioembolic
stroke (ie, history of hypertension, DM, previous stroke or
transient ischemic attack, or ≥75 years of age).2 Chronic
anticoagulation is also reasonable in patients with chronic
HF who have atrial fibrillation but are without an additional
risk factor for cardioembolic stroke. The selection of anticoagulation (eg, warfarin, dabigatran, apixaban, rivaroxaban,
and edoxaban) should be individualized on the basis of
several factors.
3.c. What nonpharmacologic therapy should be recommended
for this patient with respect to her HF?
• Although low-intensity exercise is recommended for chronic
HF patients to assist with maintenance of functional capacity,
bed rest during hospitalization for acute exacerbations of HF
is necessary.
• On discharge from the hospital, the patient should receive
specific education to facilitate HF self-care. The patient should
be encouraged to avoid alcohol, and a low-sodium diet (<3 g
per day) should also be recommended.
• The patient should be transferred to chronic oral diuretic therapy once a state of euvolemia is reached. Consideration should
be given to increase the patient’s diuretic dose on discharge
based on an assumption of adherence to diuretic regimen and
low-sodium diet. Recommendation: Change furosemide to
60 or 80 mg by mouth twice daily. At this time, it is not necessary to consider adding metolazone or consider changing to a
different diuretic (eg, torsemide).
• Chronic maintenance treatment with a β-blocker should be
continued in most patients requiring hospitalization in the
absence of hemodynamic instability or contraindications.
Based on the patient’s concomitant COPD, consideration may
be given to switching the patient’s β-blocker to a β1-selective
agent at an equivalent dose. Recommendation: If a switch
of β-blocker is made based on desire for β1 selectivity, change
carvedilol to metoprolol XL 25 mg by mouth daily. Continue
to double the β-blocker dosage every 2 weeks, as tolerated, to a
target dose of 200 mg once daily. (Of note, the tolerability of the
selective β-blocker at the target dose may be a limiting factor in
this patient due to potential loss in selectivity at higher doses
in variable individuals.) If a switch of β-blocker is not made,
then continue to double the carvedilol dosage every 2 weeks, as
tolerated, to a target dose of 25 mg BID (since this patient weighs
<85 kg). Recommendation: Continue current medications
for concomitant COPD, and continue to monitor pulmonary
symptoms closely with upward titration of β-blocker dose. The
β-blocker dose could be increased once the acute exacerbation
has resolved and the patient is euvolemic.
• The patient demonstrated intolerance (cough) to an ACE
inhibitor; thus, an ARB is recommended alternative therapy.
The patient is receiving a target dose of an ARB; thus, no
changes should be made in current therapy. Recommendation:
Continue valsartan 160 mg by mouth twice daily.
• The combination of hydralazine and ISDN is recommended in
patients self-described as African Americans, with moderate–
severe symptoms on optimal therapy. Consideration should
be given to adding the combination in this patient once maintained on standard therapy, including an ARB (ACE inhibitor
intolerance has been documented), a β-blocker, and a loop
diuretic. Recommendation: Hydralazine and ISDN should be
added once the β-blocker is titrated to the recommended target
dose or maximum tolerated dose. Addition of the combination
agents may be appropriate at this time; however, consideration
should be given to the additional pill burden and potential
cost.
• An aldosterone antagonist should not be considered at this time,
based on patient’s elevated SCr (SCr >2 mg/dL in a female
patient).
4.What drugs, doses, schedules, and duration are best suited for
the management of this patient?
• The addition of digoxin is not warranted at this time. Once
patient achieves optimal chronic therapy, consideration may
be given to adding digoxin for further symptom control and
decrease in risk for re-hospitalization. Consideration may also
be given for the addition of digoxin if unable to maintain rate
control for concomitant atrial fibrillation with a maximally
dosed β-blocker.
• An IV diuretic must be given initially for the acute HF exacerbation. The initial IV dose should equal or exceed the chronic
oral dose. Recommendation: Change the patient to furosemide
40 mg IV twice daily as the preferred diuretic regimen, although
furosemide 20 mg IV twice daily may be an acceptable alternative. Adjust potassium supplementation as appropriate based on
laboratory results.
• A switch from sacubitril/valsartan is not yet warranted at this
time but could be considered if the patient remains symptomatic and/or experiences hospitalization for HF despite
maximally dosed/tolerated β-blocker therapy (plus or minus
hydralazine/ISDN).
Optimal Plan
Copyright © 2017 by McGraw-Hill Education. All rights reserved.
• The addition of ivabradine should not be considered based on
the patient’s concomitant atrial fibrillation.
15-5
• Recommendation: Continue low-dose aspirin, due to the
patient’s significant cardiovascular history, which includes
CHD and MI.
• Medications known to adversely affect the clinical status of
patients with current or prior symptoms of HF should be
avoided or withdrawn whenever possible. Pioglitazone is
a thiazolidinedione, which carries a US black box warning
stating that these agents may cause or exacerbate HF and are
not recommended for use in patients with symptomatic HF.
Recommendation: Pioglitazone should be discontinued in this
patient with pulmonary and peripheral edema and symptomatic HF. Continue single agent glimepiride at the current dose
based on controlled diabetes mellitus (A1C 6.1%). Continue
to monitor control of diabetes mellitus and consider increasing
dose of glimepiride if necessary.
• Recommendation: Advise and encourage the patient to continue with nonpharmacologic lifestyle modifications, including low-sodium diet, alcohol avoidance, and low-intensity
exercise.
Outcome Evaluation
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?
Efficacy parameters:
• Monitor fluid intake and urine output daily during the acute
initial stages of diuresis.
• Assess the patient for improvement in her exercise tolerance.
• Initially, evaluate body weight daily to assess the efficacy of
diuresis; the long-term goal is to return her body weight to her
baseline level. Continue follow-up assessments at each visit to
determine the patient’s volume status and weight.
• Assess the patient at each visit for understanding and adherence with dietary sodium restrictions and medical regimen.
• Assess the patient’s ability to perform routine and desired
activities of daily living at each visit. The patient’s quality of life
can be assessed using standard scales.
Adverse effect parameters:
• Signs and symptoms of hypovolemia (eg, light-headedness,
hypotension, and tachycardia); vital signs should be measured
frequently during the initial stages of diuresis.
• Monitor serum electrolytes, especially potassium and sodium,
daily initially and then periodically thereafter.
Disease parameters:
• The role of serum BNP levels at this time is limited to the
initial diagnostic evaluation and classification of patients with
possible HF. BNP (or NT-proBNP) levels should be assessed
in all patients suspected of having HF especially when the
diagnosis is not certain. However, the value of serial measurements of BNP to guide therapy in the acute setting is not well
established.
• Repeat assessment of EF may be most useful when the patient
has demonstrated a major change in clinic status. Routine
assessment of EF at frequent, regular, or arbitrary intervals is
not recommended.
Patient Education
6.What information should be provided to the patient about the
medications used to treat her HF?
General information:
• It is important for you to take each medication daily exactly
as prescribed. Even if you feel fine, do not stop taking your
medications or change your dosage unless instructed to do so
by your healthcare provider.
• Contact your healthcare provider if you notice any new or
increased shortness of breath or cough; difficulty breathing when lying flat; increased swelling in your legs, feet, or
abdomen; increased fatigue or weakness with usual activities;
chest pain or palpitations; or light-headedness, dizziness, or
fainting.
• It is advisable to weigh yourself at the same time of the day,
every day. It is suggested to use the same scale every morning
and weigh yourself without clothes, after using the bathroom,
and before eating. Keep a record of your daily weights and
contact your healthcare provider if your weight increases by
3 lb overnight or 5 lb in 1 week.
• Check with your healthcare provider before starting any new
medications, including nonprescription remedies.
• Be sure to keep all follow-up appointments with your healthcare provider.
Furosemide:
• Furosemide is a diuretic that is used to maintain appropriate
fluid balance in patients with HF. It is also called a “water pill,”
which helps the body get rid of extra fluid so the heart does not
have to work as hard.
• The amount of your diuretic may change depending on how
much fluid is stored in your body. Your healthcare provider
will tell you the correct dose and number of times to take the
medication each day.
• While taking this medication, you will notice an increase in the
amount of urine or in your frequency of urination. This medication is short-acting so you will have to go to the bathroom
more frequently during the first few hours after taking your
diuretic. Since you are taking your medication two times a day,
take the first dose in the morning and the second dose no later
than 4:00 pm so you will be less likely to have to get up to use
the bathroom at night.
Copyright © 2017 by McGraw-Hill Education. All rights reserved.
Heart Failure with Reduced Ejection Fraction
• A dihydropyridine calcium channel blocker (eg, amlodipine)
may be considered for additional BP lowering in HF patients.
However, standard therapy for HF patients (ie, agents that
have been shown to reduce morbidity and mortality in clinical trials) should be titrated to target doses prior to initiation
of a dihydropyridine calcium channel blocker for further BP
control. With the initiation of an agent such as amlodipine,
patients should be closely monitored due to risk of developing peripheral edema (a known side effect of dihydropyridine
calcium channel blockers), as well as for possible reflex tachycardia in patients with concomitant atrial fibrillation. Nondihydropyridine calcium channel blockers (eg, verapamil and
diltiazem) should be avoided in patients with HFrEF.
• Renal function tests (blood urea nitrogen and SCr) should be
assessed daily initially to monitor for prerenal azotemia resulting from overdiuresis.
CHAPTER 15
• Continue chronic anticoagulation therapy due to concomitant atrial fibrillation. Recommendation: Continue warfarin
therapy to maintain therapeutic INR (goal INR 2–3). Given
that the patient’s INR is currently within this range, no dosage
adjustment in warfarin is indicated at this time.
15-6
SECTION 2
• If you miss a dose, take it as soon as you remember, unless it is
almost time for your next dose. Do not skip your diuretic when
you are away from home.
• This medicine sometimes causes dizziness and lightheadedness, especially when getting up from the lying or sitting position.
Cardiovascular Disorders
• Contact your healthcare provider if you experience dry mouth
and/or increased thirst associated with decreased urine output,
skin rash, tingling or loss of hearing, irregular heartbeat, fever
or chills associated with sore throat, nausea and vomiting, or
mood changes.
• While taking a diuretic, your blood should be checked periodically to make sure that your potassium level is normal. You
should only take a potassium supplement if told so by your
healthcare provider.
Metoprolol XL or Carvedilol:
• Metoprolol XL (or carvedilol) is in a class of drugs called
β-blockers. It is used to control BP as well as heart rate and
reduce the workload of the heart in patients with HF.
• (If change is made from carvedilol to metoprolol XL): This
medication replaces your carvedilol and may be less likely to
have negative effects on your COPD.
• This medication should be taken by mouth once (if metoprolol XL; twice if carvedilol) daily with or without food. Your
healthcare provider will slowly increase your dose until you
reach the target or recommended dose for patients with HF.
• If you forget to take a dose, take it as soon as you remember. If
it is almost time for your next dose, skip the missed dose and
return to your regular schedule.
• This medicine may cause dizziness, light-headedness, or fainting. Notify your healthcare provider if you notice any of these
symptoms or if you experience weight gain, difficulty breathing, or reduced urine output.
• During the early phases of this drug therapy, you may actually
feel worse as the dose is gradually increased. This is normal and
should improve over time.
• It is important to remember that this medication provides
long-term improvement by reducing flare-ups of HF symptoms and prolonging survival.
Valsartan:
• Valsartan is in a class of drugs called ARBs. It is used to control
BP and reduce the workload of the heart. This class of drugs
may be prescribed for individuals unable to tolerate an ACE
inhibitor, which is the case for you, as you reported a cough
while taking an ACE inhibitor previously.
• This medication can be taken by mouth twice daily with or
without food.
• If you forget to take a dose, take it as soon as you remember. If
it is almost time for your next dose, skip the missed dose and
return to your regular schedule.
• This medicine may cause dizziness, light-headedness, or fainting, especially during hot weather. Notify your healthcare
provider if you notice difficulty breathing; changes in urinary
pattern; or swelling of the face, lips, or tongue.
• While taking this medication, you will need to have your blood
drawn occasionally to monitor potassium levels and kidney
function.
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Hydralazine/ISDN:
• The combination of hydralazine and ISDN is used to control
BP and reduce the workload of the heart in patients with HF.
• The combination of medication should be taken by mouth usually three times a day. Two separate medications may be used
together, or your physician may prescribe one “combination” pill.
• If you miss a dose, take it as soon as you remember, unless it is
almost time for your next dose.
• The combination of medication may cause headaches, especially right after you start taking the pills. They may become
less intense as you continue taking the pills, and you may take
acetaminophen to help with the headaches.
• Other commonly reported side effects include dizziness,
nausea, vomiting, feeling light-headed, or even fainting. The
combination of medication may also cause low BP.
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