Two weeks later Mrs LL’s potassium is reported as 6.6 mmol/L. What is likely to have caused this and what would you recommend?
Treatment of Heart Failure and Appendix D – Practical Notes
BACKGROUND READING
Myocardial infarction; secondary prevention – NICE Guidelines 2007 – quick reference guide. May 2007
Chapter on Congestive Cardiac Failure) in Clinical Pharmacy and Therapeutics or similar textbook
PRE- WORKSHOP LEARNING – A HEART FAILURE FORMULARY
For each of the following group of drugs for heart failure indicate initiation and maximum dose and what stage of heart failure they should be used.
Beta-blockers (Licensed in heart failure)
When are they indicated:…………………………………………………..
Name Initiation dose Maximum dose
Angiotensin Converting Enzyme Inhibitors
When are they indicated:…………………………………………………..
Name Initiation dose Maximum dose
Angiotensin II Receptor Antagonist (Licensed in heart failure)
When are they indicated:…………………………………………………..
Name Initiation dose Maximum dose
Aldosterone Antagonists
When are they indicated:…………………………………………………..
Name Initiation dose Maximum dose
Loop diuretics
When are they indicated:…………………………………………………..
Name Initiation dose Maximum dose
Thiazide diuretics
When are they indicated:…………………………………………………..
Name Initiation dose Maximum dose
WORKSHOP THREE: ANSWER ALL THESE QUESTIONS USING THE READING LIST IN THE PREVIOUS PAGE TO HELP YOU ANSWER THESE QUESTIONS PLEASE ANSWER THEM IN DETAIL
Mrs LL a 70 year old lady attended her GP practice as she had noticed that she had become increasingly tired and short of breath on carrying out her usual activities.
PC Increased tiredness, SOB and swollen ankles
HPC She noticed she needed to stop for breath when walking up the stairs.
Feeling tired and lethargic as not sleeping well at night for the last 2/52. Legs are feeling heavy and her shoes feel tight.
PMH IHD, OA, MI 4 yrs ago
SHx Lives alone in a house, usually independent, doesn’t drink any alcohol, ex-smoker, quit after her MI
RS Basal creps in both lower bases, cough for past week producing watery sputum
CVS BP 150/95mmHg Pulse 90bpm reg
CNS Grossly intact
O/E Pitting oedema on both feet
Weight today = 67kg
Last recorded weight (4 months ago) in practice records = 60kg
Working diagnosis: Heart failure/COPD/General deterioration
Current Rx: Simvastatin 40mg nocte
Aspirin dispersible 75mg mane
Atenolol 50mg Mane
Ramipril 1.25mg Mane
GTN spray 400mcg 1-2 sprays when required for chest pain
1. What do you understand by the term heart failure?
2. What medical conditions can lead to the development of heart failure?
3. What signs and symptoms does Mrs LL have that may be suggestive of
heart failure? How do these arise?
4. How would the diagnosis of heart failure in Mrs LL be confirmed?
5. What treatment option would you add to Mrs LL whilst she is awaiting her ECHO and specialist review? Include a suggested dose, preferred route of administration,
any monitoring required, and counselling you should offer Mrs LL.
Mrs LL is seen by a Cardiologist and her ECHO confirms that she has Left Ventricular Systolic Dysfunction (LVSD) with an Ejection Fraction of 30%. The aetiology of her
heart failure is due to ischaemia. The Cardiologist felt no further interventions or stents would be beneficial and optimisation of medical management was the plan.
Mrs LL was referred to the local Community heart failure nurses for optimisation.
On her first appointment the recommendation is to titrate ramipril to 2.5mg daily and switch atenolol to bisoprolol 2.5mg once daily.
6. Why are angiotensin converting enzyme (ACE) inhibitors and beta-blockers recommended first line in the management of heart failure?
7. a) How should ACE therapy be titrated and what monitoring is required?
b) What are the main side effects of ACE inhibitors? How should they be managed?
8. a) How should beta-blockers be initiated in heart failure and what monitoring is required?
b) Why was Mrs LL switched from atenolol to bisoprolol?
c) In which situations are beta –blockers contra-indicated?
d) What are the main side effects of beta –blockers and how can they be managed?
9. Mrs LL wants to know how many pints of water she can drink in a day? Calculate and advise Mrs LL. (1 pint = 568ml)
Mrs LL attends for a follow up appointment at the heart failure clinic she has noticed an increase in breathlessness since her last appointment and simple things like
brushing her teeth and getting dressed can make her extremely tired. Her osteoarthritis pain has worsened and her GP has given her a new prescription for her pain.
Current Treatment:
Simvastatin 40mg nocte
Aspirin dispersible 75mg mane
Bisoprolol 10mg Mane
Ramipril 10 mg Mane
Furosemide 40mg Mane
GTN spray 400mcg PRN
Naproxen 500mg TDS
Bloods: Creatinine 120micromol/L (60-120), urea 9mmol/L (2.5-7.5), potassium 4.5mmol/L (3.5-5)
BP 130/80mmHg, HR 65bpm. mild ankle swelling and lungs clear.
10. Using the New York Heart Association (NYHA) functional classification,
how would you grade the severity of Mrs LL’s heart failure? Give reasons for your answer.
11. Could any of Mrs LL’s drug treatments exacerbate her heart failure? If so,
how? Can you suggest alternative treatments that would not exacerbate her heart failure? Fill this in on your care plan.
12. Which other classes of drugs can precipitate or exacerbate heart failure?
13. If Mrs LL’s heart failure were not controlled on her first-line agents, what second-line agents are available to add in?
14. Two weeks later Mrs LL’s potassium is reported as 6.6 mmol/L. What is
likely to have caused this and what would you recommend?
Pharmaceutical care plan for Mrs LL (on review clinic at question 11)
Problem Desired Outcome Assessment Actions
Options Follow up / monitoring Counselling
Worsening Heart Failure symptoms following titration of ACEi and BB.
Osteoarthritis
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