Pharmacological Therapy of Heart
Failure: Case presentations
Steven W. Harris MHS, PA-C
Heart Failure

Complex diagnosis that results from
structural or functional disorder(s) which
impair the ability of the ventricle to fill
with or eject blood. – ACC 2005
Epidemiology



Prevalence
 Affects 5+ million Americans currently,
>600,000 new cases diagnosed each year. 23
million people worldwide.
 Estimates are based only on symptomatic HF.
Cost
 Annual direct cost is >10 billion dollars
Frequency
 It is the most common inpatient diagnosis in
the US for patients over 65 years of age
 In 2004, there were over one million
hospitalizations in the US with a first listed
discharge diagnosis of HF
Major Determinants of Cardiac
Function
Ventricular systolic function
 Ventricular diastolic function
 Ventricular preload
 Ventricular afterload
 Cardiac rate and conduction
 Myocardial blood flow

Ventricular Systolic Function
Systolic dysfunction accounts for 6070% of all cases of HF
 Ejection fraction decreased

 55-65%
normal
 40-50% mild
 30-40% moderate
 <30% severe systolic dysfunction
NYHA Classification
Class I - symptoms only at activity
levels that would limit normal
individuals
 Class II – symptoms with ordinary
exertion (moderate exertion)
 Class III - symptoms with less than
ordinary exertion (minimal exertion)
 Class IV - symptoms at rest

Heart Failure Stages
Stage A — High risk for HF, without
structural heart disease or symptoms
 Stage B — Heart disease with
asymptomatic left ventricular dysfunction
 Stage C — Prior or current symptoms of
HF
 Stage D — Advanced heart disease and
severely symptomatic or refractory HF

Classification of HF severity
ACC/AHA HF Stage1
NYHA Functional Class2
A At high risk for heart failure but without
structural heart disease or symptoms
of heart failure (eg, patients with
hypertension or coronary artery disease)
B Structural heart disease but without
symptoms of heart failure
C Structural heart disease with prior or
current symptoms of heart failure
D Refractory heart failure requiring
specialized interventions
None
I Asymptomatic
II Symptomatic with moderate exertion
IIISymptomatic with minimal exertion
IV Symptomatic at rest
SA et al. J Am Coll Cardiol. 2001;38:2101–2113.
York Heart Association/Little Brown and Company,
1964.
Adapted from: Farrell MH et al. JAMA. 2002;287:890–897.
1Hunt
2New
Treatment Objectives



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Decrease Symptoms
Improve tissue perfusion
Increase exercise tolerance
Quality of/Prolong Life /Survival
Correct aggravating/precipitating factors:
 Endocarditis
 Arrhythmias
 Obesity
 Pregnancy
 Hypertension
 Infections
 Physical activity
 Hyperthyroidism
 Dietary excess
 Thromboembolism
 Medications




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 Preload
 Afterload
 Ionotropy
Optimize
chonotropy
 Neurohormonal
activity
Vicious Cycle
Chronic HF
Home
SOB, Wt gain
IV Lasix +/-admit
Providers office
ER
PO Lasix
Case 1

76 y/o moderately obese male with a
history of CAD with associated CABG
x 4, presents to your clinic c/o
dyspnea on exertion, 2 pillow
orthopnea, bilateral lower extremity
edema.
Case 1

Meds:

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
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

Simvastatin 80mg po qhs
Synthroid 125 mcg po qd
Lisinopril 5 mg po qd
Metoprolol 50 mg po qd
ASA 81 mg 2 tabs po qd
PMH


Physical exam:

Vitals
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
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


??

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BP: 146/78
HR: 78 regular
RR: 12 bpm
T: 98.6 F
SPO2: 95% on RA
JVD at 5 cm above
sternal angle
Bilateral rales to
mid lung fields
1+ bilat pedal
edema
Case 1

Plan:




Diagnostics:
Treatment:
Patient Education:
Follow-up/
Referrals:
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
Echocardiogram
BMP
BNP
Lasix 20 mg po qd
KCL 10 meq po qd
f/u in 1 wk
Case 2

65 y/o female who is 6 months s/p
AWMI c/o 10 lb weight gain over 72
hours. Associtated sx include
orthopnea, pnd, dyspnea at rest and
abdominal “fullness”. At the time of
discharge 6 months prior she had an
ischemic cardiomyopathy with an EF
of 50%
Case 2

Meds:



Quit meds
ASA 81 mg 1 tab po qd

Physical exam:



DM
HTN
Dyslipidemia
BP: 130/78
 HR: 100 regular
 RR: 18 bpm
 T: 98.7 F
 SPO2: 90% on RA
JVD at 10 cm above
sternal angle
Hepato-Jugular reflux
to angle of mandible
Bilateral rales 2/3 up
1+ bilat pedal edema

PMH

Vitals
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
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Case 2

Plan:




Diagnostics:
Treatment:
Patient Education:
Follow-up/
Referrals:



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Admit to hospital
Echocardiogram
CMP, BNP, CBC…
Lasix 40 mg IV x 1




Then 40 mg po BID
Enalapril 2.5 mg
BID
Simvastatin 20 mg
qhs
Morning labs
Case 2

Morning Results:

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
Diuresed 3 liters
Feeling much better
EF 45%
BNP 550
Vitals:
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BP 122/76
HR 78
RR 12
T 98.6
SPO2 98 % on 2 L
Plan

Plan:

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Wean O2
Carvedilol 3.125 mg
BID
Continue
Furosemide dose
Morning labs
Beta blockers
Case 3

65 y/o male with known history of
prior MI and CABG, ischemic
cardiomyopathy with an EF of 30%
presents to the ER with dyspnea at
rest. He states that over the last
week he has gained “at least 10 lbs”
and has been sleeping in his
armchair.
Case 3

Meds:

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Carveidolol 12.5 mg BID
Lisinopril 5 mg qd
Atorvastatin 40 mg qhs
Furosemide 80 mg qAM
ASA 81 mg 1 tab po qd
PMH


HTN, Dyslipidemia
??

Physical exam:

Vitals

BP: 110/78
 HR: 110 regular
 RR: 22 bpm
 T: 98.7 F
 SPO2: 88% on RA
Sitting upright
JVD above angle of the
mandible
Hepato-Jugular reflux
to angle of mandible
Diffuse bilateral rales
2+ bilat pedal edema
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


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Case 3

Plan:




Diagnostics:
Treatment:
Patient Education:
Follow-up/
Referrals:


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Admit to hospital
Echocardiogram
CMP, BNP, CBC…
Bumetanide 1 mg
IV then 0.5 gtt
KCL repletion
2 gm sodium diet
Case 3

Results


Diuresed 4 liters
Weaned from IV to
PO Furosemide

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80 mg po qd
Cr 1.5
Slowly gaining H2O
weight
What can you do?
Sequential nephron
blockade.
Addition of
aldosterone
antagonist

Sequential nephron
blockade with:


Metolazone 2.5 mg
po qd
Aldosterone
antagonist


Spironolactone 25
mg daily
f/u labs


K+ in 3 days and
one week.
Increased Risk of
hyperkalemia if Cr
>1.6
Case 3

Consideration of positive inotropes


Dobutamine 2-20 mcg/kg/min IV
 Indications: insufficient cardiac output
 Effect: Increase Cardiac output and stroke
volume
 Comment: Tachycardia, hypertension,
hypotension
Dopamine. 2-20 mcg/kg/min IV

Indications: Insufficient cardiac output, hypotension,
reduced renal perfusion
 Effect:
Increase cardiac output, stroke volume,
and renal blood flow

Digoxin
Digoxin



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Mildly positive inotropic effects
Associated with symptomatic improvement,
increase exercise tolerance, and clinical stability
Pts taking digoxin are less likely to be
hospitalized (25% reduction) due to CHF.
Additive benefits to Diuretic, ACE, Beta blocker
therapy
Case 4

60 y/o male with known history of
CAD and prior MI presents to your
clinic to establish care. He states that
over the last month he has had to
double his water pill to keep his legs
thin and breathe well at night. His
most recent EF was 50% one year
ago. Currently he is feeling fine, but
has SOB with riding his road bike.
Case 4

Meds:

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
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Enalapril 20 mg qd
Cardizem CD 180 mg qd
Atorvastatin 40 mg qhs
HCTZ 25 mg 2 tabs po qd
ASA 81 mg 1 tab po qd
Naproxen 220 mg qd
PMH


HTN, Dyslipidemia
??

Physical exam:

Vitals
BP: 118/78
 HR: 64 regular
 RR: 12 bpm
 T: 98.7 F
 SPO2: 97% on RA
JVD 3 cm above sternal
angle
Clear lung fields
Trace bilateral pedal
edema




Case 4

Plan:




Diagnostics:
Treatment:
Patient Education:
Follow-up/
Referrals:


DC Cardizem
Start:
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
Carvedilol 6.25 mg
BID and uptitrate
to 12.5 mg BID in
two weeks
DC Naproxen
Consider
acetaminophen
BMP to eval K+
Echocardiogram
F/u 2 weeks
Case 5

80 y/o female c/o of 1 week h/o
palpitations and 3 days of SOB and
orthopnea
Considerations
African Americans
 CRF
 ACE intolerant
