Heart Failure Case Study

When it comes to Heart Failure the best form for a brighter future is to optimise the intervention with treatment goals that are vital for the patients’ health, well-being and gain a better chance of longevity.

The benefits of obtaining a compatible medication treatment goal for the patient, is so to reduce the stress and anxiety for the patient, which in turn can minimise hospital admissions.

Anyone that has other cardiovascular risks such as diabetes, smoking, excessive alcohol (with young adults; with excessive alcohol consumption, they may be susceptible to ‘holiday heart syndrome’ which it is also known as) (Sanders, et al. 2012, p.628) and elevated blood cholesterol levels.

The following case study was given freely from a neighbour on his present health.

I have changed his name to protect his confidentiality.

Case study:

Mr Lloyd is a 73 years old widower and has heart failure in the form of Atrial Fibrillation.

He started to become breathless after riding his bike; that he did daily. He said that he also noticed excitable flutters in his chest, but did not take much notice as he thought it was because he had over exerted on an activity at his time of life and put it down to the aging process.

He popped to his local General Practitioner with his experiences and was put on a low dose of Warfarin. After a couple of weeks he returned and told his General Practitioner that he was not feeling any better and did not feel right. His General Practitioner told him to continue his dosage for another week.

Mr Lloyd enjoyed walking if he was not cycling, but, due to the weather he left the bike at home. While on his way he slipped on ice and banged his head on the pavement. He was taken to hospital for the rest of the day due to a possible concussion. At the point of leaving he complained he still had a headache. The doctor was not surprised as he had banged his head and prescribed pain relief and told him what to watch out for with head injuries (They were aware of his medication he was on at the time).

After a week of pain relief he still did not feel right. His daughter took him to a different hospital. The doctor asked what medication he was on and told him that he was on still on the warfarin, they took him off it immediately, and replaced with a very low dose of aspirin. They immediately took him for a MRI (magnetic resonance imaging) scan that revealed that he had a haemorrhage on the brain; it had been there since the fall.

History:

• There is not a family history of heart failure.
• Has not smoked for 50 years.
• Does not have any previous illnesses.
• Has never drank alcohol.
• Has worked away from home outdoors all of his working life until retirement.
• Admitted that his diet improved since his retirement, as with his previous job required him to be away from home quite a lot of the time and so his lifestyle then contained of hotels and bar meals.
• Has never been a big eater and portions were always small.

Signs and symptoms:

• Feeling breathless on light activities, more so when cycling
• Feeling weak and more tired
• Dizzy after excursion
• Pale but not all the time.
• No sickness
• Heart beating too fast, rhythm was irregular
• No coughing
• Not confusion
• No weight gain as always active
• BP normal
• No depressive feelings or cognitive problems

Tests done:

• Auscultated lungs for changes – non were found
• Blood test was taken
• Blood Pressure – high on his visit, but often fluctuated between normal and high
• Neck veins checked – no distension found
• ECG that read Atrial Fibrillation
• Electrocardiogram was performed for 24 hours
• No chest x-ray was performed
• Pitting oedema was slight at the end of the day

Medication before fall:

• Warfarin – was later changed to Aspirin
• Salbutamol inhaler
• Furosemide (unable to remember dose)
• Cod liver oil 2 spoonful’s twice a day – home remedies

(On further reading on drugs.com I was curious regarding his cod liver oil intake and the medication of warfarin he was taking that may interact due to it containing vitamin K, this reduces the effectiveness of the warfarin and flagged an air of caution) (drugs.com)

Mr Lloyd still suffered tiredness and breathlessness.

Medication after fall for 4 months:

• Aspirin
• Cod liver oil 2 capsules twice a day – home remedies
• Pravastatin 20mg – 1 daily (reduces the bad cholesterol)
• Salbutamol – when required
• Simvastatin 20mg – 1 daily (changed from pravastatin also reduces bad cholesterol)
• Spiro inhaler – when required

(drugs.com)

Mr Lloyd was told to weigh himself every morning as he got out of bed. This was so he could take part in his own progress on any weight gain or weight loss due to the change of medication and possible fluid retention. He noticed the frequency during the day and maybe once at night in going to urinate.

With the changed medication Mr Lloyd still suffered tiredness and was breathlessness on light activities.

After a review with a specialist his present medication treatment plan is:

• Apixaban 5mg – 1 x 2 daily (reduce the risk of stroke & clots)
• Atorvastatin 10mg – 1 daily
• Cod liver oil 2 capsules daily – home remedies (not spoonful’s anymore)
• Digoxin 125mcg – 1 daily (makes the heart beat stronger and a regular rhythm)
• Dutasteride 0.5mg – 1 daily (used with Tamsulosin, reduce risk of urinary blockage)
• Omerprazole 20mg – 1 daily (acid reflux)
• Spiro inhaler – when required
• Tamsulosin hydrochloride 400mcg m/r capsules 1 daily– muscle relaxant, ease flow of urine

(drugs.com)

This drug therapy is working well and clear from any adverse reactions and only visits the General Practitioner twice yearly. Blood pressure is stable at 110/75 bpm. His weight has not changed.

Mr Lloyd still charts his input and output of fluids. With this, he is able to monitor and report to his now General Practitioner any noticeable differences, to which, there is not any.

Current status:

Even though Mr Lloyd had to endure some frustrating discomfort with tiredness and breathlessness from past medications, these just didn’t suit him, (It may have been a perfect combination for somebody else) and the time it had to take to get the correct treatment goals and drug therapy to his own body’s balance, Mr Lloyd is continuing his everyday activities without any problems of breathlessness or tiredness that have hugely decreased. He has decided with himself and with agreement from his General Practitioner that after about 17.00 he will start to slow down, and relaxes after food, and will potter in his garden instead of cycling. I have only ever known Mr Lloyd to cycle everywhere and all day. He tells me that he now enjoys seeing a television programme to the end instead of falling asleep half way through. His medication has slowed down his ventricular rate and that he will go for another review later on this year. Mr Lloyd said that he would not mind if the dose was lowered or none at all as he does not like to be reliant on medication.

The specialist Doctor after reviewing Mr Lloyd advised him to attend a rehabilitation gym (sponsored by the British Heart Foundation) to monitor his exercise regime and to teach him how to keep fit in a healthy way for his age. They also educated him on a tasteful diet without the worry of blandness. He still goes to the gym, mainly because he has made many friends with similar conditions, and able to swap ideas. Mr Lloyd values the presence of the professional medical staff that are there for any health or heart concerns.

Treating congestive heart failure with medication:

To optimise the correct and suitable medication would be to find the patients correct balance. This will take a selection of medication over a period of time in order to reach the optimum goal of drug therapy. The reason for this is to make less strain on the heart by using the correct combination of drug and its correct dosage. We must try and increase the cardiac output so the blood can pump more blood every minute. This will in turn improve the pumping action of the heart and reduce the hearts workload. So medication or a medical intervention may be suggested, the severity or damage would be taken into consideration. If there is a valve problem, it may be fixed with a repair or a replacement. If a more invasive form of fixing is needed, surgical implants may be required. This may be a pacemaker. This is a ventricular assisted device that contains a pulse generator with one, two or three electrode leads that give off electrical impulses to and from the heart (British Heart Foundation 2014, p.13)(Cleland 2006, pp.72-44). A more severe case may include a heart transplant which includes a recently deceased donor that is a match for the recipient. There are risks involved like any other surgery, but a heart transplant may be rejected due to rejection, infection or the new heart does not work properly. (Cleland 2006, pp.79-80)

We need to take the effort off the workload on the heart by decreasing the fluid overload and reduce the blood pressure, so medication to reduce the heart rate and increase vasodilation (widen the blood vessels, by relaxing the smooth muscle cells). Diuretics would be one solution that would help with the fluid overload. This will increase the urine output and so in turn decreases the fluid overload. Different diuretics such as thiazide and loop diuretics that will cause a general loss of sodium and water from the body but also other electrolytes (minerals in the blood). This must be monitored for hypokalaemia (low potassium) because of sodium and water loss, potassium can be lost from the body in large quantities. (Cleland 2006, pp.54-63)(Class notes 2014/15)

Another diuretic is a potassium sparing diuretic, it is an aldosterone antagonist (blocks the sodium retention effects of aldosterone in the kidney). This may cause a reverse problem, the potassium sparing diuretic can cause the body to retain too much potassium, so the patient must be monitored for hyperkalaemia (high potassium). An imbalance of hypokalaemia or hyperkalaemia in the body will be a risk of the electrical problems in the heart. By using diuretics the patient will be monitored for hypotension (low blood pressure) this is due to the fluid retention and the reduction of blood pressure medication. You must also monitor serum creatinine (waste product in the blood that comes from muscle activity and kidney function indicator). If the levels of this get too high, it will be an indication that the kidneys are having problems. (Class notes 2014/15)(Cleland 2006, pp.59-63)

Other medications that will be help congested heart failure is to now focus on the blood vessels, the aim is to stimulate the function of the vasodilation that will rest the heart by slowing it down. The most used medication is called an ACE inhibitors (Angiotensin-converting enzyme) (Cleland 2006, pp.53-56) this will block the enzyme that forms angiotensin II also known as ARBs (angiotensin receptor blockers) (Cleland 2006, pp.56-57) this causes the vasoconstriction to raise the blood pressure. The ACE inhibitor will interrupt the cycle of angiotensin II, this will then decrease the blood pressure. The increase of vasodilation with the ACE inhibitors and vasodilation will lower the blood pressure and so helps to reduce the workload on the heart. There will be a drop in aldosterone (is a corticosteroid hormone that stimulates absorption of sodium by the kidneys) levels causing a decrease in fluid overload.

A medication called ARBS (Angiotensin Receptor Blockers) reduce the activity of the angiotensin II in the blood. You would prescribe this if the patient is not able to tolerate an ACE inhibitor. (Class notes)(Cleland 2006, pp.56)

Beta blockers block the binding of norepinephrine (neurotransmitter) to the beta receptors on the heart, this will cause a decrease in the heart rate.

Which in turn will decrease the blood pressure and the workload of the heart. With such an amount of medication, it is advisable to monitor the patient for hypotension.

(Class notes 2014/15)(Cleland 2006, pp.57-59)

References:

Bibliography

• British Heart Foundation (2014) Pacemakers.
• Chronic heart failure | introduction | Guidance and guidelines (no date) Available at: http://www.nice.org.uk/guidance/cg108/chapter/introduction (Accessed: 13 May 2015)
• Cleland, J. (2006) Understanding heart failure. London: Family Doctor Publications in association with the British Medical Association
• Prescription Drug Information, Interactions & Side Effects (no date) Available at: http://www.drugs.com (Accessed: 14 May 2015)
• Sanders, M. J., Lewis, L. M., Quick, G. and McKenna, K. D. (2012) Mosby’s Paramedic Textbook [With DVD]. 4th edn. United States: Elsevier/Mosby Jems

Citation

• (Chronic heart failure | introduction | Guidance and guidelines, no date)
• (Prescription Drug Information, Interactions & Side Effects, no date)
• (Sanders et al., 2012, p. 628)
• (British Heart Foundation, 2014, p. 13)
• (Cleland, 2006, p. 56)
• (Cleland, 2006, pp. 57 – 59)
• (Cleland, 2006, pp. 57 – 59)
• (Cleland, 2006, pp. 56 – 57)
• (Cleland, 2006, pp. 53 – 56)
• (Cleland, 2006, pp. 59 – 63)
• (Cleland, 2006, pp. 54 – 63)
• (Cleland, 2006, pp. 79 – 80)
• (Cleland, 2006, pp. 72 – 74)Case study given freely by my neighbour.