CLINICAL CASE

Done by:

Haneen Burgan 201710496

Raneen Ammar 201710375

Sana Zakria 201710623

Course Instructor: Dr. Zelal Kharaba

Course Name: Hospital Pharmacy - Training

Course Code: 0204590

Chronic Diastolic (Congestive) Heart Failure

TABLE OF CONTENTS

Demographics of HF

Patient presentation

Drug therapy problem

Treatment

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2

3

4

5

Counseling and monitoring

1

Demographics of Heart Failure

What is Heart Failure?

• Heart failure is a progressive clinical syndrome that can result from any disorder that impairs the ability of the ventricle to fill with or eject blood.

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1. Increased ventricular stiffness

• Ventricular hypertrophy
• Infiltrative myocardial disease
• Myocardial ischemia and infarction

2. Mitral or tricuspid valve stenosis

3. Pericardial disease (e.g., pericarditis, pericardial tamponade)

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Etiology

Systolic Dysfunction (decreased contractility)

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Diastolic Dysfunction (Restriction in ventricular filling)

Epidemiology

80% men & 70 % women up to 65 years will die within 8 years

~ 550,000 HF cases /year

Men > Women

33 billion $$ are spent /year

PATHOPHYSIOLOGY

• Heart not providing tissues with adequate blood.
• Elevation of pulmonary\systemic venous pressures.
• A change in cardiomyocyte function.
• can result from diastolic\systolic function abnormalities

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• can be a change in cardiomyocyte function
• Changes in collagen turnover
• Cardiac structural defects
• Rhythm abnormalities
• High metabolic demands

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Cardiac output (CO) = HR x SV

Clinical representation of HF

• SOB

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Signs and symptoms

• Fatigue

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• Dizziness

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• Coughing

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• Edema

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• Lack of appeptite (nausea)

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• S3 gallop

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• palpitations

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• Hepatojugular reflux

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2

Patient presentation

Chief complaint (CI)

A 62-year-old man is complaining of constant weight gain with SOB

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HPI: history of present illness

AGE: 62 years

GENDER: male

ALLERGIES: NKA

1

2

3

A.K presents to the hospital with SOB and lower extremity edema.

Symptoms started 1-1.5 weeks ago.

Gaining 2 Ib daily

4

Using albuterol\ipratropium MDI for his COPD symptoms

PMH, FH, SH

PHYSICAL FINDINGS

Increased shortness of breath from baseline

X chest pain

Dyspnea on exertion

20-Ib weight gain over the past week

BP 156/92, P 80 (regular), RR 24, T 36.9°C; Wt 100 kg (usual weight 90 kg)

• Chronic venous stasis changes on bilateral lower extremities
• 2+ pitting pedal edema bilaterally

Obese with a nontender, nondistended abdomen

Laboratory results

Imaging and other studies

1. ECG - Sinus rate of 70; QRS 0.08; no ST–T wave changes; low voltage
2. CXR - Interstitial edema and some early alveolar edema
3. 2D echocardiogram (2 Years ago) - Diastolic dysfunction & preserved systolic function (EF 55%)
4. Recent 2D echocardiogram:
1. Impaired ventricular relaxation and elevated left atrial filling pressures (Grade II diastolic dysfunction)
2. EF = 44%
3. Dilated inferior vena cava

Drug therapy problems

• Adverse drug events that must be monitored:
• Aspirin + Amlodipine
• Metformin + furosemide
• Furosemide + Carvedilol
• Amlodipine + Carvedilol
• Aspirin + Carvedilol

• Amlodipine is contributing to the patient's pedal edema.

• Edema therapy should be intensified

• Patient’s BP is uncontrolled (>20\10 mmhg than the target), therapy should be intensified

• High dose salicylate is contributing factor to his HF

• Needs additional anticoagulant agent for his STEMI CAD and low INR (risk of blood clot)

• STATIN therapy should be intensified

3

Treatment

• Improve quality of life
• Relieve / reduce the symptoms
• Prevent / minimize hospitalizations for exacerbations of heart failure
• Slow progression of the disease process
• Prolong survival�

DESIRED OUTCOME

https://www.acc.org/latest-in-cardiology/articles/2018/02/28/12/19/diabetes-management-in-older-adults-with-cvd

PHARMACOLOGICAL TREATMENT

PHARMACOLOGICAL TREATMENT – CONT.�

1000 mg

81 mg

20 mg

NON-PHARMACOLOGICAL INTERVENTIONS

• Restrict dietary sodium (<2g/day)
• Restrict fluid intake (2L/day)
• DASH diet (fruit, vegetables, and fish, as well as poultry and nuts)
• Reduce intake of saturated fats <7% of total calories, trans fatty acids <1% of total calories and cholesterol <200 mg/day.

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• Weight loss plan (~ 5-10%)
• Limit his physical activity
• Stable & excess fluid removed? 🡪 encourage physical activity

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• Avoid tight socks or stockings that slow blood flow to the legs and cause clots.

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• Use pillows to prop up head

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4

Counseling and Monitoring�

Counselling

SL nitroglycerin

Diuretics

Bisoprolol

ACEI (Enalapril)

• Take your first dose before bedtime
• When getting out of bed or standing up move slowly
• Restrict food rich in potassium

Information should be provided to the patient about the medications used to treat his heart failure

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• After the first dose be careful operating heavy machinery or driving until are aware of how the drug affects you
• Move slowly when getting up 
• Limit food rich in SALTS ( calcium, sodium, magnesium)

•  Take the pill in the morning 

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• 1 tablet may be used every 5 minutes as needed for chest pain, for up to 15 minutes.
• Do not take more than 3 tablets in 15 minutes
• place the tablet under your tongue  and wait for it to dissolve.
• You may feel burning or tingling in your mouth as the tablet dissolves

Counselling

Clopidogrel plus low dose aspirin

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Information should be provided to the patient about the medications used to treat his heart failure

• Take these 2 together daily
• The most common side effects of Clopidogrel are getting out of breath and bleeding more easily than normal. 

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Monitoring (Non-laboratory parameters):�

Chest x-ray

Pulmonary function testing (PFT)

• Electrocardiogram (ECG)
• 2D Echocardiogram

Physical examination

• Blood pressure
• Weight

Exercise stress test

Monitoring (Laboratory parameters):�

• Troponin
• BNP
• Electrolytes
• SrCr
• HbA1c
• PT/INR
• Lipid profile

REFERENCES

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• Diagnosis and management of Diastolic ... - AAFP Home. (n.d.). Retrieved November 6, 2021, from https://www.aafp.org/afp/2006/0301/afp20060301p841.pdf.
• Diabetes management in older adults with cardiovascular disease. American College of Cardiology. (n.d.). Retrieved November 1, 2021, from https://www.acc.org/latest-in-cardiology/articles/2018/02/28/12/19/diabetes-management-in-older-adults-with-cvd.
• BMJ Group. (2020). Bnf 80: September 2020 - March 2021.
• DiPiro, J. T. (2020). Pharmacotherapy: A pathophysiologic approach. McGraw Hill.

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THANKS!

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