Hello Dr., Redden, and Class, according to the ACC/AHA guidelines, this patient is in stage C heart failure. This stage is comprised of patients who are symptomatic and also have structural damage such as Myocardial infarction (Papadimitriou, Hamo, & Butler, 2017). Evidence in this case study that supports categorizing this patient to this stage of heart failure includes myocardial infarction in 2010 (structural damage), symptoms such as shortness of breath that gets worse with activity, shortness of breath that wakes her up at night that resolves with sitting upright with 3 pillows (Orthopnea), feeling of fainting and lightheadedness (Vertigo), and lower leg edema.
Stage C heart failure is also categorized into 2 sections: those with an EF greater than 45% (Diastolic heart failure) and those with an EF less than 45 % (Systolic heart failure). This Patient has an EF of 39% which shows she has Systolic heart failure.
According to the ACC/AHA guidelines Stage C, systolic heart failure should be treated with diuretics and heart rate control in addition to the treatment of other comorbidities that the patient might have (Yancy et al.
, 2017). Factors that need to be taken into consideration for this patient include; being an African American, LVEF of 39%, BNP 682 pg/ml, Triglycerides 188, HDL 37, Cholesterol 230, and LDL Cholesterol 190.
This patient needs the addition of the following types of medication to her current medication regimen, an anti-hypertensive, a beta-blocker, and a diuretic. Hydralazine and isosorbide dinitrate will be the anti-hypertensive of choice due to being an African-American (Papadimitriou, Hamo, & Butler, 2017). Hydralazine and isosorbide dinitrate increase cardiac index by 58%, reduces the left ventricular filling pressure by 40% and reduces the systemic vascular resistance by 38%.
Isosorbide dinitrate leads to a reduction in preload while hydralazine leads to a reduction in afterload. This combination therapy leads to a better response than each drug used individually (Fedele, Severino, Calcagno, & Mancone, 2014).
Due to this patient’s history of Myocardial Infarction, and addition of a beta-blocker is recommended. Beta-blockers are beneficial in patients with a history of recent myocardial infarction regardless of their LVEF, provided there is no contraindication (bradycardia, heart block). In patients with heart failure, beta-blockers reduce the effect of catecholamine stimulation, increased myocardial energy demands, elevate heart rate, and also reduce adverse cardiac remodeling (Papadimitriou, Hamo, & Butler, 2017).
A diuretic is required to reduce the symptoms of pulmonary or peripheral congestion. Spironolactone is an aldosterone antagonist that prevents the formation of the protein needed for sodium-potassium exchange at the distal convoluted tubules in the kidneys. This in turn prevents salt and fluid buildup. (Fedele, Severino, Calcagno, & Mancone, 2014).
The above prescriptions have no refills because this patient will be re-evaluated after completing this prescribed dose for effectiveness. If symptoms persist, dosing will be titrated until symptom relief and improved quality of life are achieved. However, this patient will also be educated to call the office if worsening symptoms are experienced, which may require adjustment of doses before the initially scheduled follow-up. She will be educated on the need to fill her prescriptions as this is the only way to relieve her symptoms and improve her quality of life.