Download Case Study for Chronic Cardiac Failure

TREATMENT OF VENTRICULAR ARRHYTHMIAS-A CASE STUDY
TREATMENT OF VENTRICULAR ARRHYTHMIAS-A CASE STUDY
The life expectancy of An Australian, is about 79.9 years for the males and 84.3 years for
the female. One of the causes of death is a number of chronic diseases, the definition a chronic
disease is a serious disease that may or may not be spread directly from one person to the other
may result from several factors that include someone’s genetic make-up, their lifestyle and
environment. Heart disease is one of the chronic diseases that cannot be spread directly from one
person to another and is one of the major causes of deaths in Australia.
Cardiac arrest is the abrupt loss of heart function that someone may or may not be
diagnosed with a heart disease. Death occurs shortly after the symptoms appear. Cardiac arrest
occurs when there are arrhythmias caused when the heart’s electrical system does not function
properly. An attempt to reverse cardiac arrest is the performance of cardiopulmonary
resuscitation (CPR) to the person and a defibrillator is used to shock the person under cardiac
arrest in order to restore normal heart rhythm within a few minutes. A sudden cardiac arrest may
be caused by any heart or related condition.
Among the determinants of someone’s vulnerability to heart diseases, include tobacco
use and excessive consumption of alcohol among other risk factors. In Australia, there is a high
number of smokers with the more disadvantaged areas having more daily smokers1,2. In 20112012, around 1 in 5 adults indulged in harmful alcohol use that exposed them to lifetime harm.
1
ABS 2013e. Australian Health Survey updated results, 2011-2012 Canberra ABS.
2
ABS 2013f. Austalian Health Survey. Updated results , 2011-2012 Canberra. ABS
The case of patient AC, is an 85 year old female diagnosed with chronic cardiac failure,
she has smoked and consumed alcohol for around 35 years. Preventive measures that patient AC
could have taken include non- indulgence in tobacco use and consumption of alcohol. Before I
prescribe patient AC is any kind of palliative care, I ensure that her diagnosis is confirmed by the
measurement of ventricular function by transthoracic echocardiography. Transthoracic
echocardiography involves an ultrasound for the heart in addition to the clinical signs and
symptoms recommended by the National Heart Foundation and the Cardiac Society of Australia
and New Zealand Chronic Heart Failure Clinical Practice Guidelines Writing Panel. These
guidelines are aimed at strengthening the quality of remaining life for the patient by ensuring that
the condition does not deteriorate. The guidelines are achieved by drug, non-drug and surgical
procedures. The severity of her condition will be based on the symptoms shown by her
condition, with 20-30% one-year mortality probability indicating mild to moderate heart failure
and 50% one-year mortality in severe heart failure3.
The patient confirms the age statistic of those with a high risk of diagnosis with Chronic
cardiac Arrest due to their exposure to heart or related diseases. I note her age as one of the
probable contributors to the diagnosis. A majority of patients diagnosed with heart related
diseases were 75 years and over4. 90% of deaths caused by heart related diseases occurred in
people aged 75 years and over. Older age has been associated with the risk of heart diseases. The
patients that are diagnosed, however often have other accompanying conditions. I therefore test
3
Watson RDS, Gibbs CR & Lip (2000). ABC of heart failure: clinical features and
complications. British Medical Journal 320:236-9
4
AIHW: Senes S & Britt H (2001). A general practice view of cardiovascular disease and
diabetes in Australia. Cardiovascular Disease Series No. 18. Cat no. CVD 17. Canberra: AIHW.
the patient to find if she has any of the other accompanying conditions, which may also have
been among the contributors to her chronic cardiac failure condition. The accompanying
conditions include high blood pressure that results in cardiomyopathy, which is a thickened heart
muscle and diabetes, that are common with the diagnosis of patients with the accompanying
condition of diabetes found to be higher. The tests shoe the patient has high blood pressure.
Before giving my prescription I put into consideration that the medication I give her
might also result in a sudden cardiac arrest and as her diagnosis is chronic it might be fatal. Some
heart medications that have increased the risk of the patient include antiarrhythmitic drugs used
to treat arrhythmias, which may result in fatal ventricular arrhythmias and may cause sudden
cardiac arrest.
Common causes of cardiac arrest that may have resulted in diagnosis of the patient’s
condition, diagnosis also include, scarring resulting from a previous heart condition, this can be
eliminated as they are no previous records of any previous heart condition. Another cause is drug
use for purposes of pleasure purposes for those without organic heart disease. After inquiry the
patient confirms that they are not involved in such activity.
According to the Sudden Cardiac Arrest Foundation5, the regulation of the numbers of
those that die from cardiac arrest depends on care taken at the different levels. One is preventive
measures taken for those at risk. Another is the ability of someone to provide immediate care for
someone under cardiac arrest this will depend on the availability of defibrillators at the scene and
5
Sudden Cardiac Arrest Foundation. Retrieved from http://www.sca-aware.org accessed on may
13 2015
whether they have been trained on its use6. Also, is the care given to those successfully
resuscitated from sudden cardiac arrest? Since the condition of the patient was not prevented.
She should be with someone able to administer a CPR to her and were in a place with such
equipment in case she is discharged at all times. The prompt response to emergency cases by
CPR has resulted in saving of a lot of lives.
Studies suggest that 75% to 80% cases of sudden cardiac arrest are attributed to
Ventricular Fibrillation (VF) which is recorded at the time of sudden cardiac arrest and pulseless
ventricular tachycardia (VT). The other 15% to 20% are attributed to bradyarrhythmias,
advanced atrioventricular (AV) block and asytole7. EP mechanisms investigated for the onset of
VF/VT its continuation has demonstrated no class I or III antiarrhythmitic agent resulting in
reduction of Sudden Cardiac Death (SDC) mortality for patients at risk. Investigations reveal
that instead drugs without direct EP action on cardiac muscles or specialized conducting tissue
have been effective for prevention of SCD. The drugs include beta blockers, ACE inhibitors,
angiotensin receptor blocking agents, lipid-lowering agents spironalactone and fibrionolytic and
antithrombotic agents. The following drugs therefore help in narrowing down my prescription to
her.
Evaluation of patients with documented or suspected ventricular arrhythmias
6
Drezner J.(2007). Inter-association task force recommendations on emergency preparedness and
management of sudden cardiac arrest in high school and college athletic program: A consensus
statement. Heart Rhythm 4:549-565
7
Cummings R.(1991). Improving survival from sudden cardiac arrest: The “chain of survival”
concept: A statement for health professionals from the Advanced Cardiac Life Support
subcommittee and the Emergency Cardiac Care Committee, American Heart Association.
Circulation.83
The severity of her cardiac disease increases her risk of Sudden Cardiac Death than even the
frequency or classification of ventricular arrhythmia. The patient was established to have
ventricular arrhythmia after undergoing a number of evaluations that include,
Checking her for palpitations, presynscope and syncope were one of the initial indications of the
patient having ventricular arrhythmias. A thorough drug history was also carried out for the
patient. Her family history of SCD also showed vulnerability of her to ventricular arrhythmias
and SCD. High intake of nicotine from tobacco use was also an indicator. The patient underwent
echocardiograph in order to accurately diagnose myocardial, valvular, and congenital heart
disorders associated with ventricular arrhythmias. Echocardiography was also used to evaluate
the patients Left Ventricular systolic function and wall regional motion. The combination of
echocardiography and pharmacological stress was applied in order to determine whether the
patient’s ventricular arrhythmias was caused by ischaemia as she has no resting ECG
abnormalities which then limited the accuracy of ECG for ischemia detection. A background,
economic check for my patient reveals that she is not very able economically. I therefore
recommend health care, government programs for her that may be able to help. This is because
economic constraints play a role in the incidence of Sudden Cardiac Arrest. This is because of
skipping of the cardiac medications due to lack of money for the purchase of the prescribed
medication.
Therapies for ventricular arrhythmias
The management of the patient’s condition was carried out in a number ways that
include. One is drug therapy. She is given beta blockers as opposed to antiarrhythmitic drugs
because of their potential lethal effects. Beta blockers were effective in suppressing ventricular
arrhythmias. They are safe and effective antiarrhythmic agents. The drugs work by competitive
adrenergic receptor blockade of sympathetically mediated triggering mechanisms and slowing
down the sinus rate.
Special Considerations Where Antiarrhythmic Drugs are indicated
The patient was also diagnosed with ICD, therefore prescription of an the antiarrythmic
drug amiodarone. The combination of beta-blockers and amiodarone is effective in suppressing
ventricular arrhythmias due to the patients low EF and poor renal function.
Nonantiarrhythmic drugs
Alternatively, the patient would be prescribed to administration of potassium and
magnesium that can favourably influence the EP substrate involved in ventricular arrhythmias.
Another alternative is surgical therapy, this may involve ablation or surgical resection of an
arrhythmogenic focus, cardiac sympathectomy or aneurysm resection. Surgical also has
revascularization also has favourable effects which include reduction in myocardial ischaemia.
Management of Cardiac Arrest
The patient is at higher risk as survival of patients with VF is greater with the exception
of patients with pathophysiological conditions such as her that favour the potential of partial
arrhythmia. The probability of survival decreases drastically within 1 to 2mins after the onset of
cardiac arrest, a brief period of CPR to provide oxygen for the patient increase the probability of
VF.
Review of Related Literature
Amiodarone is highly effective in suppression of ventricular arrhythmias and in
maintaining sinus rhythm in patients. It is used after ventricular arrhythmias has not responded to
the other antiarrhythmics. Amiodarone is available in tablets of 200 and 400mg an also available
in a solution for intravenous administration8.
The combination of Amiodarone and beta blockers has the ability to prevent shocks in the
patients receiving ICD therapy for secondary prevention of ventricular arrhythmias. ICD shocks
are life threatening to patients. ICD shocks also led to reduced physical and mental functioning.
Studies reported that patients that received no ICD shocks led a more quality life than those
patients that received ICD shocks as it even resulted in anxiety over when the next ICD shock
experience would occur. Combination of amiodarone and beta-blockers also resulted in
myocardial antiarrythmitic effects as it has direct on the sinus node, reducing heart rate which
also helped to prevent inappropriate shocks.
Common side effects include fatigue, tremor, poor coordination, nausea, vomiting,
constipation, visual disturbances, skin discoloration, rash and the worst result may be worsening
of arrhythmias. Uncommon side effects of amiodarone include, liver injury that has a higher
probability to occur with higher doses and prolonged therapy9. The liver injury caused may be
direct damage to lipid bilayers and disturbance of lysosomal and mitochondrial function.
Amiodarone may also cause A different form of liver injury when administered intravenously in
high doses to elderly patients. Injury caused by amiodarone may be fatal, resulting in liver failure
8
Vasallo P, Trohman.(2007). Prescribing amiodarone:an evidence based review of clinical
indications. JAMA. 298
9
Varma R, Troup P, Komorowski, Sarna T.( 1985).Clinical and Morphological effects of
amiodarone on the liver. Gastreonterology.88 1091-3
and that will result in death10. However, in situations where amiodarone is considered totally
necessary, liver biopsy should be used in monitoring the occurrence and extent of liver injury, if
any, and guide whether medication should be stopped or the patient should continue taking the
required dose.
Palliative Care
Palliative care is aimed at improving the value of life and providing of support to patients
and close relatives of the patients that is their family for patients that have been diagnosed with
serious or chronic illness. Palliative care takes a holistic approach and aims to meet not only the
patients different needs that are physical, emotional, spiritual and even logistical but also meet
the needs of their caregivers11.
Palliative consultations result in earlier referrals to hospice. Earlier referrals are
associated with higher family satisfaction brought about by awareness of what the family should
expect at the time of death and higher participation in the care of patients at home. Later referrals
often result in the families’ dissatisfaction with the hospice services as they have a relatively
short time to comprehend the situation. This is may be in terms of understanding that a hospice is
for patients diagnosed with chronic illness and therefore it is there to ensure that their last
moments of their life are as good as it can possibly be under their circumstances. The family
should therefore be able to keep in mind that the patient's condition will deteriorate.
Palliative care is categorized in hospice palliative care and non-hospice palliative care.
During a patient's illness palliative care would have to move from non-hospice palliative care to
10
Lwaktere J. Morris , Knight EJ.(1990) Fatal Fulminating Liver Failure Possibly Related to
amiodarone treatment. Br. J Hosp Med44:60-1
11
Lynn J, Teno, Philips.(1997). Perceptions by family members of dying experience of older and
seriously ill patients. ANN Intern Med 126:97-106
hospice palliative care. This decision should be made by all concerned parties which will
probably include the patient and their loved ones. A decision to take that action may also be
influenced by the assessments of the patient’s condition and determination that they have a few
months to live. Another determinant would be the increase in frequency of hospitalization of the
patient. Instead of movement of the patient in and out of the hospital, it is recommended that his
patient be taken to a hospice to provide ‘comfort’ as the patient can be with family and as well be
able to receive the necessary medical attention12.
Palliative care for patients has been found to increase the quality of life for patients
diagnosed with heart disease chronic cardiac arrest being one among many. Palliative care
increases the patients' quality of life by improving patient satisfaction and it also reduces the cost
of care. This should then reduce the patient’s expenditure as the other forms of treatment are
quite costly. It is has also been recommended for the end stage in heart diseases.
Patients living with serious illness identified some of their needs as appropriate pain and
symptom management. The patients would like for their conditions should be managed in a way
that results in the least pain for them. Patients would also like palliative care to take care of
unnecessary prolongation of dying. Patients would like to relieve their loved ones the burden of
deciding whether the life support system should be cut off even when there probability of their
survival is quite low. Patients would therefore like for them to be let to rest when the nurses have
done all they can but their body's response to it has been very minimal and is deteriorating13.
12
Conor SR.(2007)Development of hospice and Palliative Care in the United States. Omega
56:89-99
13
ibid
Palliative care improves the overall outcome of the situation. Patients who receive nonhospice palliative care have a high probability to die at home. This should be so if the patient and
his/her family have decided that this is what they would wish. It may also result due to economic
constraints facing the family. The patient and family would then prefer to implement nonhospice palliative care in order to prevent accumulation of massive hospital debts which they are
unable to cater for this kind of palliative care may also be preferred due to the recent studies that
have shown an improvement in survival by 81days as compared to those that were not in the
hospice. This can be attributed to avoidance of hospital stays.
Palliative care also impacts on health care use and costs. Palliative care decreases the
number of procedures undertaken towards the end of life, the length of stay of patients in
inpatient wards and intensive care unit and also reduced pharmaceutical costs. This results in an
overall decrease of total costs under palliative care. It also results in hospice savings, where
hospice programs save about 40% at the end of life stage and about 17% in the last six months of
a patient's life.
Difficulty has however been encountered on the determinants of when it is recommended
for a patient to be transferred to a hospice. In an attempt to solve this it was recommended that
prognostic factors be used to determine whether the patient is at the end of life stage. Goals of
care should then be established for all patients diagnosed with a chronic illness. Pain should be
addressed at every visit to ensure that the patient does not experience unbearable pain that
reduces their quality of life14.
14
Schockett E, Teno J, Miller s. (2005). Late referral to hospice and bereaved family member
perception of quality of end of life care. J Pain Symptom manage. 30:400-407
Advance care planning also includes communication. The palliative approach advocates
for shared decision making between the patient, caretakers and the medical team. Discussion of
specific interventions such as CPR helps the patient to discuss conditions that might create fear
and confusion for them.
Palliative care is also concerned with evidence-based approaches to the symptoms. Some
of the suffering that patients go through is pain. Opioids may be used as a pain reliever although
here is a risk of addiction of the patent to it15. Patients may also go through depression that may
result in increased number of hospitalization events. To manage depression other underlying
factors such as pain should be addressed. Psychotherapy and cognitive behavioural therapy may
also be helpful in reducing depression in patients. Fatigue is also another difficulty which the
patients experience and can be reduced by stimulants. At the end of stage of heart diseases for
instance, chronic cardiac arrest discontinuation of medical therapy may result in the quality of
life. This may be due to the development of other conditions that may be as a result of the
medications. To ensure the quality of life these drugs may have to be withdrawn.
15
Ibid
References
ABS 2013e. Australian Health Survey updated results, 2011-2012 Canberra ABS.
ABS 2013f. Austalian Health Survey. Updated results , 2011-2012 Canberra. ABS.
AIHW: Marthers C&Penn R. (1999). Health Sytem Costs of cardiovascular diseases and diabetes
Australia 1993-1994. Health and Welfare Expenditure Series no. 5cat n. HWE 11
Canberra: AIHW.
AIHW: Senes S & Britt H (2001). A general practice view of cardiovascular disease and diabetes
in Australia. Cardiovascular Disease Series No. 18. Cat no. CVD 17. Canberra: AIHW.
Boutitie F, Boissel I, Connolly S, EMIAT(European Mocardial Infarct Amiodarone Trial) and
CAMIAT(Canadian Amiodarone Myocardial Infarction Trial) investigators. Amiodrane
interaction with beta blockers:analuysis of merged EMIAT and CAMIAT databases.
Connolly SJ. Evidence based analysisof amiodrane efficacy and safety.
Conor SR.(2007)Development of hospice and Palliative Care in the United States. Omega 56:8999
Cummings R.(1991). Improving survival from sudden cardiac arrest: The “chain of survival”
concept: A statement for health professionals from the Advanced Cardiac Life Support
subcommittee and the Emergency Cardiac Care Committee, American Heart Association.
Circulation.83
Drezner J.(2007). Inter-association task force recommendations on emergency preparedness and
management of sudden cardiac arrest in high school and college athletic program: A
consensus statement. Heart Rhythm 4:549-565
Lwaktere J. Morris , Knight EJ.(1990) Fatal Fulminating Liver Failure Possibly Related to
amiodarone treatment. Br. J Hosp Med44:60-1
Lynn J, Teno, Philips.(1997). Perceptions by family members of dying experience of older and
seriously ill patients. ANN Intern Med 126:97-106
Schockett E, Teno J, Miller s. (2005). Late referral to hospice and bereaved family member perception of
quality of end of life care. J Pain Symptom manage. 30:400-407
Stuart J. Connoly, DoriAN, Roberts R, Gent M, Bailin S, Talajic for the Optimal
Pharmacological Therapy in Cardioveter Defibrillator Patients(optic) investigator.(2006)
Comparison of Amiodrane plus B-Blockers for prevention of shocks from implantable
cardioveter defibrillators. JAMAvol 295(2).
Sudden Cardiac Arrest Foundation. Retrieved from http://www.sca-aware.org accessed on may
13 2015
Varma R, Troup P, Komorowski, Sarna T.( 1985).Clinical and Morphological effects of
amiodarone on the liver. Gastreonterology.88 1091-3
Vasallo P, Trohman.(2007). Prescribing amiodrane:an evidence based review of clinical
indications. JAMA. 298
Watson RDS, Gibbs CR & Lip (2000). ABC of heart failure: clinical features and complications.
British Medical Journal 320:236-9