The patient’s heart failure should be classified as moderate to severe, left ventricular heart failure (Stage C). The ejection fraction (EF) determines how well your heart is able to sufficiently pump blood. The normal ejection fraction is 55%-70%. An ejection fraction of 30% is deemed to be extremely low and life-threatening. Based on her EF, she is having heart failure with reduced ejection fraction. There need to be adjustments made to the patient’s current medication regimen. I could either increase the HCTZ to 25mg PO daily or add furosemide of 20-40 mg PO daily because it is the more effective drug for heart failure. The change will improve her symptoms by reducing the amount of fluid in her body, allowing her to breathe easier. Diuretics acting on the loop of Henle, are more effective for the treatment of heart failure than thiazide diuretics, acting on the distal tubule (Biondi-Zoccai et al, 2017). This will improve her symptoms of edema. In the long-term taking HCTZ or furosemide. The patient would have to discontinue the use of taking her ibuprofen because it is an NSAID and they are contraindicated because they can create sodium retention and reduce the effectiveness of diuretics. I would inform her to take Tylenol for her arthritic knee pain.
The verapamil that the patient is currently taking is contraindicated in individuals with any degree of heart failure. I would discontinue that order and start her on a more conducive medication like hydralazine. Vasodilators have been shown to reduce mortality in patients self-prescribed as African-Americans with NYHA class III-IV HFrEF. They are also recommended to reduce morbidity and mortality in patients with current or prior symptomatic HFrEF who cannot be given ACE inhibitor or ARB because of drug intolerance, hypotension, or renal insufficiency, unless contraindicated (Ghandi et al., 2017). In the long-term, hydralazine and furosemide don’t have any long-term negative outcomes. In order to monitor parameters for HCTZ, if prescribed could potentially cause kidney failure so I would advise her to have her levels checked every 6 months. Also, with the use of Tylenol, I would recommend she only take the minimum dosage (no more than 3000mg daily) necessary to alleviate her knee pain in order to reduce hepatic toxicity. I would also have her come back in 3 months following medication adjustments/changes to determine if her EF has improved.
There are a few non-pharmacological recommendations for this patient. The long-term goal of the treatment and management of heart failure is to avoid exacerbation of heart failure and to decrease the hospital readmission rate (Inamdar & Inamdar, 2016). I would inform the patient of her new diagnosis to ensure she understands why these new changes are imperative. I would recommend that she would attempt to lose weight because she is only 62 inches tall, but she weighs 139 lbs. That equals a BMI of 25.42 which classifies her as being obese. I would encourage her to increase her physical activity and reduce her sodium intake. It is unclear if the patient smokes or consumes alcohol. If she does, I would encourage her to reduce and/or stop smoking or drinking alcohol.
References:
Biondi-Zoccai, G., Borges, A.R., Resende, E.S., & Roever, L. (2017). Drugs used to treat heart
failure with reduced ejection fraction. Current Trends in Cardiology, 1(1), 8-11.
https://doi.org/10.35841/cardiology.1.1.8-11
Ghandi, D., Mansukhani, R., Shah, A., Shah, K.J., & Srivastava, S. (2017). Heart failure: A
class review of pharmacotherapy. Pharmacy and Therapeutics, 42(7), 464-472.
Inamdar, A. A. & Inamdar, A.C. (2016). Heart Failure: Diagnosis, management and utilization.
Journal of Clinical Medicine, 5(7), 62.