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CHRONIC HEART

FAILURE
Acosta, Vincent
Alvarez, Marianne
Antig, Sofia
Bajao, Sarah
Ballesteros, Veronica
Bondoc, John
Bustilla, Janelle
Capellan, Stephen
Caruyan, Duke
Cifra, Manuel
Concepcion, Thea
Crudo, Ian
Daud, Abraham Jr.

OBJECTIVES

Identify the salient features of the following


conditions:
Acute

heart failure
Chronic heart failure

Formulate a therapeutic regimen for the case


Correlate the regimen with the pathophysiologyic
mechanism of the disease
Make prescription of the drugs to be used in each
case
Give sound patient education
Formulate a sound follow-up and monitoring
scheme

General Data: 51 year old male from Fairview Quezon City


Chief Complaint: Dyspnea
History of Present illness
Present condition started 6 months ago prior to
consultation. The patient complains of having difficulty in
breathing every after 4 flights of stairs but since he can
recover by resting, he did not seek any consultation. 1
month PTC, the patient noticed that while exercising for
about 10 mins, he feels dizzy and complains of difficulty in
breathing. 2 weeks PTC, he noticed that it occur, dyspnea,
taking a bath and even lifting grocery bags, but it was
relieved by resting. He feels fatigued most of the day and
this lead him to this consultation.

Physical Examination

The patient is conscious and coherent.


BP: 140/90 RR: 23 cpm PR: 98 bpm Temp: 36.8
Skin: unremarkable
HEENT: anecteric sclera, no palpable lymph nodes, + JVD
to 12 cm, no bruits
Chest: equal chest expansion, Decreased breath sounds
Heart: Normal S1 and S2. Presence of S3 sound, point of
maximal impulse (PMI) was displaced downward and
laterally
Abdomen: flat, soft with normoactive bowel sound, no mass
or tenderness
Extremities: + edema bilaterally on foot. Cyanotic fingers

Past medical history


Patient was diagniosed HPN. Taking amlodipine
5mg as his maintenance drug but does not take the
medicine on time and regularly.
Personal and social history
Patient states that he used to smoke but he quit
smoking 1 year ago. Not alcohol drinker. He is a cargo
loader in a wet market.

LABORATORY
BNP (Brain-Type Natriuretic Peptide) 749 pg/mL
NT-proBNP 1,246 pg/mL

Fasting:
Total cholesterol 4.65 mmol/L (180 mg/dL)
LDL
2.3 mmol/L (90 mg/dL)
HDL
1.55 mmol/L (60 mg/dL)
Triglycerides 1.46 mmol/L
(130 mg/dL)
Urinalysis: Negative
ECG: atrial fibrillation, elevated t waves
CXR: Positive cardiomegaly

Component

Result

Normal Value

WBC COUNT

9.00

4.5 11.0

RBC COUNT

3.90

4.32 5.72

HEMOGLOBIN

11.50

13.5 17.5

HEMATOCRIT

37.40

38.8 50.0

MCV

86.40

80 100

MCH

29.39

27 31

MCHC

34.50

32 - 36

221

150 - 420

Neutrophil

4.3

1.8 7.8

Lymphocyte

2.0

0.7 4.5

Monocyte

4 13

Eosinophil

0-7

PLATELET COUNT
Differential Count

SALIENT BASIS OF THE


DISEASE AS BASIS OF
DIAGNOSIS

HISTORY
Comorbidities

factors

and/or risk

Cardiomyopathy
Valvular

heart disease
Alcohol use
Hypertension
Diabetes
Dyslipidemia
Coronary/Peripheral
vascular disease
Sleep-disordered breathing

Collagen

vascular
disease, rheumatic fever
Pheochromocytoma
Thyroid disease
Substance abuse history
History of
chemotherapy/radiation
to the chest

SIGNS AND SYMPTOMS


Exertional dyspnea
Dyspnea at rest
Orthopnea
Acute pulmonary edema
Chest pain/pressure and
palpitations
Tachycardia
Fatigue and weakness
Nocturia and oliguria
Anorexia, weight loss,
nausea
Exophthalmos and/or
visible pulsation of eyes

Distention of neck veins

Weak, rapid, and thready pulse

Rales, wheezing

S 3 gallop and/or pulsus alternans

Increased intensity of P 2 heart sound

Hepatojugular reflux

Ascites, hepatomegaly, and/or anasarca

Central or peripheral cyanosis, pallor

PROBLEMS OF THE
PATIENT THAT WOULD
REQUIRE
PHARMACOLOGICAL
INTERVENTION

Dyspnea and fatigue

Sensitivity

is 66%.
Specificity is 52%.

Edema

on feet + cyanosis on fingers

History

of smoking, hypertension, and obesity


Inadequate supply of oxygenated blood

Hemoglobin

, hematocrit and LDL

Hemoglobin and hematocrit- below normal range


LDL with other lipid components- elevated

BNP and nt-probnp


Most

important diagnostic tools


nt-probnp elevated

No heart failure

100pg/ml

Presence of heart failure

100-300pg/ml

Mild heart failure

Above 300pg/ml

Moderate heart failure

Above 600pg/ml

Severe heart failure

Above 900pg/ml

Cardiomegaly + atrial fibrillation


Stress

Workload

=> hypertrophy

RATIONALE OF DRUG USED

FOR CHRONIC HEART FAILURE CLASS 2 AND 3 SOME OF THE


GROUPS OF DRUGS USED ARE:

Diuretics

Aldosterone receptor antagonists

Angiotensin-converting enzyme inhibitors

Angiotensin receptor blockers

Beta blockers

Cardiac glycosides

Vasodilators

Drug Group

Drugs

Beneficial Effects

Diuretics

Thiazides,
furosemides,
spironolactone

Reduced preload,
afterload; Spirono
lactone reduces
aldosterone effects

Cardiac glycosides

Digoxin

Positive inotropic effect

Vasodilators

Hydralazine,
isosorbide dinitrate

Reduced afterload,
preload

Angiotensin
antagonists

Captopril, losartan

Reduced remodeling,
preload, afterload,
apoptosis

Beta blockers

Carvedilol, metoprolol

Reduced afterload,
reduced remodeling,
apoptosis

DIURETICS
First

line treatment

Symptomatic

relief (edema)

Spironolactone
Aldosterone-blocking

agent

ACE INHIBITORS
Inhibit

the production of Angiotensin II


Potent vasoconstrictor
Enalapril

Reduction

of heart size
Reduced requirement for other
medication for heart failure

Ace inhibitors, when added to


diuretics, improve symptoms, exercise
tolerance, and survival and hospital
admission rates in chronic heart
failure.

INSTRUCTION OF
DRUG INTAKE

SPIRONOLACTONE
Tablet
Oral intake
Once or twice a day
Reduced-salt (sodium) diet
Daily exercise program
Avoid potassium-containing
salt substitutes

ENALAPRIL
Shake the oral suspension (liquid) well
Use dosing syringe or special dose-measuring
spoon or medicine cup
You may take enalapril with or without food.

DIGOXIN
Capsule, or pediatric elixir (liquid)
Oral intake
Once a day


MONITORING OF
EFFICACY

SIGNS AND SYMPTOMS THAT A PATIENT CAN


EXPERIENCE AND MUST BE MONITORED
Shortness of breath
Difficulty breathing when lying down or waking
up at night with shortness of breath
Persistent cough or wheezing
Fatigue or weakness with little or no energy for
routine activities
Weight gain

Swelling in ankles, feet, legs, or abdomen


Nausea or feeling full early with meals
Abdominal pain or tenderness
Confusion or difficulty with concentration
Unusually prolonged or severe chest pain or angina
Changes in the regularity of your heartbeat
Dizziness or feeling faint when standing up from a
sitting position

EMERGENCIES
Chest pain or pressure not relieved with rest or
after taking three nitroglycerin tablets 5 min
apart
Extreme shortness of breath
Coughing up pink, frothy sputum
Fainting spell, severe sweating, or passing out

MONITORING
ADVERSE EFFECTS

SIDE EFFECTS OF ENALAPRIL


Cough
Low blood pressure/dizziness (hypotension)
Kidney problems (renal impairment)
High levels of potassium in the blood
(hyperkalemia)

SIDE EFFECTS OF
SPIRONOLACTONE
Development of breasts in men (gynecomastia)
High levels of potassium in the blood
(hyperkalemia)
Kidney problems (renal dysfunction)

SIDE EFFECTS OF DIGOXIN


Therapeutic range occurs between 0.6-1.2 ng/mL
Enlarged Breasts
Sinus Bradycardia

NONPHARMACOLOGICAL
TREATMENT/LIFESTYLE MODIFICATION

Diet

Maintenance

of optimal weight
Obesity= increases the workload on the heart
Salt intake should be restricted
Low fat diet => delay recurrence of significant
cardiovascular events
omega-3 fatty acids

Fluid

intake

Intense

thirst and hyponatraemia


2 liters a day for most patients

Alcohol

intake

Damage

the myocardium
Precipitate arrhythmias

Smoking

Increases

the risk of many cardiovascular,


pulmonary and other problems, including cancers

Exercise
Bed

rest
Regular, and moderate physical activity
Dynamic exercise activities
Long-term aerobic exercise training => reverse left
ventricular remodelling

Vaccination
Influenza

and pneumococcal vaccinations

CASE 2
**To present CLASS 3 CHF

General Data: JD, male, 51 years old from Fairview, Quezon


City
Chief complaint: Bipedal Edema

History of Present Illness:


JD is apparently well until 10 minutes prior to Admission,
Stated to have shortness of breath aggregated by prolong walling
and climbing on a stair, he needed to rest for 10-15 minutes.
Consultation was done to a private MD and was noted to have
increase blood pressure (150/90), bipedal edema He was given
Antibiotics Combizar 20mg/tablet (losartan +
hydrochlorothiocyde) to be taken 2x a day, furamide tablet, 1tab
a day, patient implied for 2weeks and offer temporary relief.
After 3 days he again experienced dyspnea, easy fatigability even
at rest, sleeps with 3 pillows, pauses when eating, experiences,
excessive sweating. He continued self medication w/ Lasix 20mg
2x a day.

Physical Examination:
General

survey: awake, coherent, slightly irritable, in


respiratory distress
BP: 150/100
RR:30 cpm CR: 110
Weight: 70kgs Temp: 36.2O2 Sat: 92%
Skin: cold clammy, CRT (Capillary Refill Time) at >2
seconds; excessive sweating; brownish spots on lower
legs
Heart: puffy eyelids bilateral; (+) alar flare; SVP
increased to 14cm
Chest/lungs: (+) intercostals retractions

(+) Bibasol crepitant rales


Heart: S3 noted with PMI 5th-6th ICS LMCL;
Increased heart rate at 110/bpm
Abdomen: (+) pitting edema of the abdomen
Extremities: Grade 3 edema; (+) palpable peripheral

Past Medical History: admitted at the age of 40


because of UTI
Family history:
History

of diabetes Father side


History of HPN both sides
History of Heart problem Both sides

Personal History
Intake

of alcohol occurred started at the age of


25years old
Smoker consuming pack a day started at the age of
15years old and at present 1 stick a day
Known varsity player in basketball from age 18-35
years old

LABORATORY
Chest

X-ray: Cardiomegaly

- Fluid level upto midlung area


- Evidence of pleural effusion
- Clinical Correlation needed

BNP

= 897pg/ml
NT-proBNP = 2343pg/ml
Fasting:

Blood Sugar = 220mg/dl


Total Cholesterol = 5.8mmol/L (195mg/dl)
LDL = 2.8mmol/L (94mg/dl)
HDL = 1.54mmol/L (79mg/dl)
Triglycerides = 1.48mmol/L (132mg/dl)

Urinalysis:

+1 Albumin
ECG: elevated ST waves; Heart rate increased