HF is a clinical syndrome caused by the inability of the

Heart to Pump sufficient blood to meet the metabolic

needs of the body.

Classifications HF:

Systolic Dysfunction (Decreased Contractility)

Diastolic Dysfunction (Restricted Ventricular
Filling)
Mixed
Chief Complaint
“I think I might have the flu. I have been feeling run down, and I haven’t
been able to get up the stairs to my bedroom because I get winded.”
HPI( history of present illness )
Richard Anderson is a 65-year-old African American man who was
brought to the ED by ambulance upon request of his endocrinologist.
The patient had called the physician’s office this morning to cancel his
routine visit for diabetes follow-up because he became short of breath
and diaphoretic after attempting to climb a flight of stairs. When
evaluated by the paramedics in his home, the diaphoresis had resolved,
and his heart rate was in the range of 100–120 bpm. The patient states
that he has been gaining weight and having progressively worsening
dyspnea on exertion over the last 5 days. His shortness of breath is often
worse at night, forcing him to “sit
bolt upright.” He began sleeping in his recliner about 3 days ago. He is
unable to complete physical activities that he could do 2 weeks ago
without difficulty.
PMH (past medical history )
Type 2 DM × 15 years, untreated until 3 years ago;
neuropathy × 2
years and retinopathy × 1 year
HTN × 20 years
Hypercholesterolemia (documented 6 months ago)
CVA × 2 (2 and 3 years ago)
Recurrent TIAs × 1 year
SH (social history )
Retired musician living alone. Prior to his CVAs, his hobby was
repairing and playing antique pump organs. He has a 30 pack-
year history of smoking but reports quitting 22 years ago. He
has a positive history for alcohol use but states he “hasn’t had
a drop in 12 years.”
 Meds
•Rosiglitazone 4 mg po once daily
•Metformin XR 1,000 mg po once daily
•Glyburide 5 mg po BID (twice daily)
•Atorvastatin 20 mg po once daily (LDL 90 mg/dL 1 month ago)
•Lisinopril 10 mg po once daily
•Aspirin/extended-release dipyridamole 25 mg/200 mg po twice daily
All
NKDA
ROS (review of system)
Reports having headaches recently, but nothing that he would consider
unusual or out of the ordinary. Denies any recent chest pain. No chronic
cough, but has had recent episodes of coughing spells without
productivity. Complains of recent abdominal bloating and of being
awakened the past four evenings to relieve his bladder. He reports some
weakness in his right lower extremity but states that it is unchanged
from his most recent stroke. He denies chronic joint pain.
 Physical Examination not appreciated. No lymphadenopathy
•Gen or thyromegaly.
The patient is sitting up on the gurney •Lungs/Thorax
in the ED in moderate distress. Respirations are even. There are fine
•VS crackles in both lung fields posteriorly
BP 150/95, P 100–120, RR 22, T 35°C; noted two-thirds of the way up the
Wt 103 kg (usual weight 93 kg), Ht lung fields. No CVAT.
5'11'' •Heart
•Skin Regular rhythm, no rubs, variation in
Color pale and diaphoretic; no unusual intensity of S1 as expected. S3 is
lesions noted appreciated at apex in lateral position.
•HEENT PMI displaced laterally and difficult to
PERRLA, EOMI, fundi were not discern.
examined. He has a complete upper •Abd
denture and about two-thirds of the Soft, NT/ND, (+) HJR, liver and spleen
teeth in the lower jaw are remaining slightly enlarged, no masses,
and are in fair repair. hypoactive bowel sounds
•Neck
(+) JVD at 30° (8 cm). Carotid bruit is
•Genit/Rect
Guaiac (–), genital examination not performed
MS/Ext
3+ pitting pedal edema bilaterally; radial and pedal pulses are of
poor intensity bilaterally; grip strength greater on left than on right
•Neuro
A & O × 3, CNs intact. Some sensory loss in both LE below the knee.
DTR 1+
• ECG
Sinus tachycardia rate of 112, QRS 0.08. Diffuse non specific ST-T wave
changes. Low voltage.
• Chest X-Ray
PA and lateral views in figure show evidence of congestive failure with
cardiomegaly, interstitial edema, and some early alveolar edema. There
is a small right pleural effusion.
Assessment
Diabetic patient with new-onset congestive heart failure
•Clinical Course
The patient was admitted to a step-down unit and placed on
telemetry. A 2D echocardiogram was obtained to evaluate LV and
valvular function (see Fig). The results showed severe LV
dilation and increased left atrial dimension, akinesia of the septum,
and severe LV dysfunction. EF was estimated at 15–20%, with no
visible clots.
1.a. Create a list of this patient’s drug-related problems.
1)Uncontrol HTN with use lisinopril but not improvement .
2)Untreated Anemia (HgP low )12.6
3) Untreated (hypomagnesemia)
4)Abnormal level of BNP and Troponin 1 thise indicate for
develop HF quicly .
5)Side effect of Rosiglitazone is HF and weihgt gain that may be
lead to disease progression .
6)Taking three type of diabetes drug without any improvment in
A1C(6.9 high ).
1.b. What signs, symptoms, and other information indicate the
presence and severity of the patient’s heart failure?
 sings symptoms
•Edema •Dysapnea
• Fine crackles •Unable to complete physical
•Pale skin activity
• liver and spleen slightly enlarged •Diaphoresis
• Early alveolar edema. •Cough
•Tachycardia •Abdominal pain
•JDV •Bloating
•HJR •Weakness
•Cool extremities •SOB
other information
•On 2D echocardiogram showed severe left ventricular dilation and increased left
atrial dimension , akinesia of the septum and sever LV dysfunction .
•EF 15-20%.
•BNP abmnormal.
•Diffuse non specific ST-T wave change.
•Low voltage .
•Devlopement hypprefusion
1.d. Could any of this patient’s problems have been caused
by drug therapy?

Rosiglitazone aggrevate
the proplem
1.c. What is the classification and staging of heart failure for
this patient upon presentation?
for this patient the staging is
(stage C, class 3)
2.a.What are the goals for the
pharmacologic management of
heart failure in this patient?
•Lower blood pressure
•Lower BNP Levels
•Adequate glucose levels
•Control to hypercholesterolemia
•improve quality of life
• relieve or reduce symptoms
•prevent or minimize hospitalizations
2.b. Considering his other medical problems, what other
treatment goals should be established?
-Consult a Ophthalmologist for Retinopathy
-Consult a Neurologist for Neuropathy
-Control of diet due to DM and Hypercholesterolemia
- Exercise appropriate for his condition
3. What medications are indicated in the long-term
management of this patient’s heart failure based upon his
stage of heart failure?

1-Loop diuretic (for dcrease fluid retention and HTN).

2-ACE Inhibitor (Because EF<40% ,↓Blood flow).
3-Beta Blocker (for decrease HTN)
Optimal Plan
4. What drugs, doses, schedules, and duration are best
suited for the management of this patient?

1-Diuretic Iv(furosmide 20-16 mg/day)

2-ACE inhibitor (Lisinopril 20 mg PO/day)
3-BB (carvedilol 3.125-mg/12 hr intial dose – daily dose 10 mg)
4-Atrovastatin 40 mg/day for hypercholesterolemia
5- Aspirin 325mg PO /day with clopidogrel for thinning blood
and keep it flowing
6-Insulin aspart 5 unit SC with Insulin glargine 20 unit SC for
diabetic
7-potassium chloride 40 mEq po /day for prevention of HTN
8-Magnesium oxide 400mg po /day for cardiac arrhythmia
Outcome Evaluation
5. What clinical and laboratory parameters are needed to
evaluate the therapy for achievement of the desired
therapeutic outcome and to detect and prevent adverse
events?

BNP level
CLINICAL COURSE
Over the next 3 days, the patient received maximal drug therapy,
and his condition improved. He underwent a cardiac catheterization and
bare metal stent placement for a 90% LAD lesion. He was discharged on
lisinopril 20 mg po daily, carvedilol 6.25 mg po BID, furosemide 40 mg
po daily, potassium chloride 40 mEq po daily, magnesium oxide 400 mg
po daily, insulin glargine 20 units SC hs, aspart insulin 5 units SC AC,
clopidogrel 75 mg po daily, aspirin 325 mg po daily, and atorvastatin 40
mg po daily.
Patient Education
Atrovastatin