A PRESENTATION ON

DECOMPENSATED
CONGESTIVE HEART FAILURE
PAUL BAFFOE-BONNIE
PATIENT PROFILE

Patient’s initials: M.K

Age: 61
Sex: M
Date of admission: 27/05/2021
PATIENT PROFILE

Presenting complaint:
Dyspnea on exertion 1/12
Easy fatigability 1/12
Abdominal distension 1/12
Bilateral leg swelling 2/12
 PATIENT PROFILE

History of Presenting Complaint:

Patient had no known chronic illness and was in
his usual state of health until 2 weeks prior to
admission, when he started experiencing easy
fatigability, dyspnea on exertion, abdominal
distension and bilateral leg swelling, which have
progressively worsened. He presented to SIC
clinic and was referred to KBTH for further
management
PATIENT PROFILE

Social History:
Insurance broker, former athlete, does not smoke, drink or ingest
recreational drugs, lives in Adeiso

Family History:
NIL OF NOTE

Past Medical History:

NO COMORBID CONDITIONS
PATIENT PROFILE

DRUG HISTORY
Patient indicated use of unspecified herbal
medications Referred with furosemide 40mg 8
hourly, aldactone 50mg daily.
PATIENT PROFILE

Relevant signs:
Distended abdomen, orthopnea,
intermittent dyspnea,ascites, pitting
edema to the knees, sacral edema, raised
JVP, irregularly irregularly heart rate, apex
of heartbeat is displaced, fine creps
bibasally, digital clubbing, liver span
reduced (6cm)
PATIENT PROFILE

Provisional Diagnosis:
1. Decompensated CCF secondary to dilated
cardiomyopathy precipitated by pneumonia

2. CKD secondary to herbal drug induced nephritis

 Current medications
Medication Dosage Start End Reason for use Comment
[name/ Route] /Frequency Date Date/
Review
date

IV Frusemide 40mg 8 hourly 27/5/21 —-—- Congestive Heart Failure Appropriate

1.2g 8 hourly 4/6/21 Bilateral pneumomia

IV Amoxiciclav 29/5/21 Appropriate

500mg daily 29/5/21 2/6/21 Bilateral pneumomia Appropriate

Tab Azithromycin

5,000IU 12 28/5/21 ———- Prevention of

Appropriate
SC Unfractionated hourly Cardiovascular events
Heparin

Tab Amlodipine 10mg daily ———- Congestive Heart Failure

28/5/21 Appropriate

IV OMEPRAZOLE 40mg daily ———— Acute Gastritis Appropriate

30/5/21
 LABORATORY INVESTIGATIONS
Biochemistry REFERENCE UNIT RESULTS
PARAMETER RANGE

27/05/21 5/05/21

Sodium 135-150 mmol/L 141 138

Potassium 3.5-5.5 mmol/L 3.2 L 3.9
Chloride 95-110 mmol/L 104 106
Serum Urea 2.0-7.0 mmol/L 7.7 H 5.7
Serum Creatinine 71-133 (Male) 62- ꭒmol/L 416 H 126 H
106 (Female)
eGFR ml/min/
1.73m2 16 L 53 L
LABORATORY INVESTIGATIONS
PARAMETER REFERENCE UNIT RESULTS
RANGE

27/05/21
Hb 11-18 g/dL 15.2

MCV
76-9L fL 91.3

MCH 27.0-32.0 pg 30.5

WBC
2.50-8.50 109/L 5.98

PLT 150-450 109/L 264

 VITALS
DATE BP/ PULSE RESPIRATOR SpO2 TEMPERATUR
MMHG RATE/BPM Y RATE/CPM E /DEGREES
CELSIUS
2/3/21 136/124 99% on
20 36.5
106 RA
3/3/21 150/122 86 20 99% on 35.5
RA
4/3/21 140/98 99% on
74 2O 35.7
RA
5/3/21 161/115 72 20 99% on 35.5
RA
6/3/21 158/108 99% on
80 20 35.5
RA
7/3/21 160/11o 76 18 99% on 35.5
RA
8/3/21 164/110 99% on
80 22 35.5
RA
9/3/21 174/112 78 19 99% on 35.5
RA
LABORATORY INVESTIGATIONS

Pylori Antigen Test (27/5/21) - Positive

LP Profile (05/5/21)
Cholesterol 4.9
LDL 3.6 high
HDL 0.8 low
Non HDL cholesterol - 4.1 High
Cholesterol/HDL ratio - 6.1

CK-MB (27/5/21)
20U/L normal
LABORATORY INVESTIGATIONS

ECG (27/5/21)
Left bundle branch block
Reduced voltages in limb and augmented limb leads

ECHO REPORT (25/5/21)

Dilated cardiomyopathy
Severe systolic and diastolic dysfunction
Severe functional mitral and tricuspid regurgitation
Severe pulmonary hypertension
LABORATORY INVESTIGATIONS

ABDOMINOPELVIC USG (25/5/21)

Cholethiasis with diffuse gallbladder wall thickening

Simple renal cyst at 2.3cm
PHARMACEUTICAL CARE
ISSUES

Contraindication for Drug

Patient is being administered Azithromycin,
which potentially may cause QT prolongation.
Patient’s ECG report showed left branch
bundle block, so azithromycin may worsen
electrical transmission abnormalities. It is
recommended that Azithromycin 500mg daily
be replaced with doxycycline 100mg bd
PHARMACEUTICAL CARE
ISSUES

Counseling issues

Patient had been on herbal medications which may

have contributed to hepatic/renal failure. Patient will
need counseling on possible toxicity of herbal
medications and interactions with allopathic
medications
PHARMACEUTICAL CARE
ISSUES

Untreated indication
Beta blockers need to be included in the management
of a Stage C Heart Failure patient, as they reduce
sympathetic compensatory mechanisms that
contribute to worsening heart failure. 2013
ACCF/AHA guidelines indicate that beta blockers
greatly reduce morbidity and mortality. This patient
was only administered furosemide for the
management of heart failure, and it is recommended
that Tab bisoprolol 1.25mg once daily be added to the
patuent’s regimen
PHARMACEUTICAL CARE
ISSUES

Drug interaction
Azithromycin inhibits the metabolism of
heparin, leading to increased anticoagulant
activity which may cause bleeding. It is
recommended that Azithromycin be replaced
with doxycycline 100mg 12 hourly
 SOAPO PRESENTATION ON
MANAGEMENT OF CONGESTIVE
HEART FAILURE SECONDARY TO
HYPERTENSIVE HEART DISEASE
SUBJECTIVE DATA

Dyspnea on exertion 1/12

Easy fatigability 1/12
Abdominal distension 1/12
Swollen legs 2/12
OBJECTIVE DATA

Pitting edema to the knees

Sacral edema
Raised JVP
Irregularly irregularly heart rate
Apex of heartbeat displaced
Severe systolic and diastolic dysfunction
found in echocardiogram
Left bundle branch block found in ECG
Severe mitral and tricuspid regurgitation
found in Echocardiogram
MEDICAL CONDITION
ASSESSMENT

HF is a complex clinical syndrome resulting from

any structural or functional impairment of
ventricular filling or ejection of blood. Cardinal
manifestations of HF are dyspnea and fatigue
(which the patient presented with), along with
fluid retention and reduced exercise tolerance.
Structural dysfunction may occur in any of the
layers of cardiac tissue (pericardium,
endocardium, myocardium), as well as the heart
valves
MEDICAL CONDITION
ASSESSMENT
. HeartFailure may be with preserved left ventricular
structure, leading to preserved ejection fraction, or
may have reduced left ventricular function, causing
reduced ejection fraction, but systolic and diastolic
abnormalities will coexist nevertheless. This patient
was shown by his echocardiogram to have reduced
LV function, causing an ejection fraction of 21%.
Heart Failure with reduced ejection fraction is
defined heart failure with aejection of less than 40%
of end diastolic volume, so he presents as Heart
Failure with Reduced Ejection Fraction.
MEDICAL CONDITION
ASSESSMENT
According to the ACCF/AHA Staging of
heart failure, the patient was shown to be in
Stage C (Structural Heart Disease with prior
or current symptoms of heart failure). It has
been shown that the patient possessed a
major risk factor for heart failure;
hypertension, as it precipitates vascular
dysfunction and worsens the process of
atherosclerosis.
MEDICAL CONDITION
ASSESSMENT
Management goals for heart failure,
particularly in stage C, are to lessen
symptoms of discomfort, improve
respiratory and cardiovascular function, and
to prevent further events of heart failure.
MEDICAL CONDITION
ASSESSMENT

Treatment options range from beta blockers

(targeted at reducing increased compensatory
sympathetic activity that may worsen cardiac
compromise), medications to reverse increased
vasoconstriction such as ACEIs/ARBs, diuretics
to combat fluid overload, and vasodilators to
reduce preload and afterload so as to reduce
pressure on
CONFIRMATION OF DIAGNOSIS

Patient’s subjective data (dyspnea, easy fatiguability,

bipedal and sacral edema) as well as objective data
(reduced ejection fraction, pulmonary hypertension,
cardiomegaly, impaired electrical conduction in
myocytes) are indicative of heart failure, according to
the 2013 ACCF/AHA guidelines on diagnosis and
management of heart failure
MEDICATION ASSESSMENT
IV Lasix 40mg 8 hourly
Patient AG was administered furosemide 40mg tds from the
referral site and continued on that regimen upon admission.
Furosemide, through its diuretic activity, reduces blood volume
and decreases fluid retention. It leads to a decrease in preload
and afterload, which places less strain on cardiac myocytes and
mitigates the symptoms of heart failure such as easy fatigability
and dyspnea (Kraus et al., 1990) Diuretic treatment is prescribed
for all heart failure patients who show, or have shown evidence
of fluid retention, according to the American College of
Cardiology(Felker et al., 2020) Loop diuretics have been shown
to have greater effectiveness and are considered the mainstay
diuretic therapy in heart failure (McMurray et al., 2013). The
patient’s diagnosis also included renal injury, and the use of loop
diuretics have been demonstrated to be beneficial in recovery
from AKI, as well as in achieving fluid balance (KDIGO
Guidelines, 2012). The dosage given, 40mg 8 hourly, falls
within the approved total daily dose in heart failure
management, which is 600mg daily, according to the
ACCF/AHA guidelines.
 MEDICATION ASSESSMENT
Tab Amlodipine 10mg daily
Amlodipine, as a dihydropyridine calcium channel
blocker, causes peripheral vasodilation, which reduces
left ventricular afterload, decreasing the excess
metabolic demands on the cardiac myocytes.
Amlodipine is not a first line agent in management of
hypertension in heart failure, as their effect on
mortality in Heart failure patients with reduced
ejection fraction are neutral (Milton et al., 2013)Other
treatment options such as beta blockers may be more
beneficial, but the ACC/AHA, as well as he heart
failure society accept amlodipine use in heart failure
based on its safety and tolerance (Hunt SA, Abraham
WT, Chin MH et al., 2005), and so 10mg daily
administration is not inappropriate for this patient,
although alternatives with benefit in heart failure
should be considered
MEDICATION ASSESSMENT
SC Heparin 5,000IU 12 hourly
The patient was administered heparin for
prophylaxis against deep vein thrombosis. Heart
failure presents relatively high risk for
development of DVT without anti-thrombolytic
therapy (Dean et al., 2010) as well as other risk
factors such as the patient’s stationary condition.
Heparin, via its inhibition of thrombin and factor
Xa, reduces the chances of DVT formation. It is
used in patients with low eGFR (Badireddy et al.,
2021) and does not require dosage adjustments for
creatinine clearance below 30ml/min
(Grand’Maison et al., 2012) and so it is appropriate
in this patient who has had varying levels of eGFR.
PLAN

Goals of Therapy:
1 ) To improve symptoms of heart
failure- edema, dyspnea, decreased
fatigability
2 ) To reduce morbidity and mortality
3 ) To improve survival rate and prevent
further instances of acute heart failure
 PLAN
Recommendations/Interventions:
1 ) Recommend to doctors that patient M.Ks be
administered Tab doxycycline 100mg bd to replace
Azithromycin 500mg daily, to prevent possibility of further
cardiac electrophysiological dysfunctions
2 ) Recommend the addition of Tab Bisoprolol 1.25mg
daily to the patient’s regimen
3 ) Counsel the patient on the use of herbal medications
and the dangers presented when used in combination with,
or to replace, allopathic medicine
4 ) Recommend the removal of amlodipine from the
patient’s regimen to be replaced by Bisoprolol 1.25mg
daily
COUNSELLING
1 ) Patientwas informed of the damage that
unsupervised use of herbal medications could cause to
the kidney and the liver, and was advised to treat
symptoms with prescribed medications with exhaustive
studies than to ensure their effectiveness and safety.

2 ) The patient was advised to report any feelings of

discomfort after taking any of the medications to any
of his doctors

3 ) The patient was informed of possible side effects of

the drugs he would be taking - gastric discomfort from
omeprazole and amlodipine, possible increased gum
bleeding from the use of heparin, and diarrhea from the
use of azithromycin. He was told that these were to be
expected, and to report to his doctor if the symptoms
became intolerable.
MONITORING

Medicati Efficacy Toxicity Test Outcome

on parameter
IV Lasix edema relief Hypokalaemia, Blood urine Patients
hyperuricaemia, electrolytes Oedema
hypocalcaemia, resolved
hyperglycemia
Tab Blood pressure Peripheral edema, Clinical BP maintained
Amlodip management dizziness, observation below
ine abdominal pain 120/80mmHg,
10mg no toxicity
observed
Unfracti DVT/PE Bleeding, Clinical No DVT/PE
onated prophylaxis thrombocytopenia observation, observed, no
Heparin Full blood bleeding
5,000IU Count observed
twice
daily
OUTCOME
Recommendations for the addition of a
beta blocker were accepted (Carvedilol
3.125mg bd), and patient was counselled
on herbal medications as well as on his
current medication regimen. Patient is
currently on admission and is being
monitored for effectiveness and toxicity
of medications.
SOAPO PRESENTATION ON
BILATERAL PNEUMONIA
SUBJECTIVE DATA

Difficulty in breathing, shortness of breath

 OBJECTIVE DATA
Fine crepitations heard in both bases of lungs
Chest X-Ray shows white infiltrates
Bronchial breathing heard
Air entry reduced bibasally
Respiratory rates from 27/5-30/5 (cpm) -
27/5/21 - 20cpm
28/5/21 - 20cpm
29/5/21 - 20cpm
30/5/21 - 20cpm
CHEST X-RAY
Demonstrates consolidation in right and left lung
CONDITION ASSESSMENT
Community acquired pneumonia (CAP) is an infection of
the lung parenchyma that is characterized by
consolidation and fluid filled alveoli that contribute to
symptoms such as cough and difficulty in breathing.
Community acquired pneumonia may be caused by
bacteria, viruses or fungi, but the most common
causative organisms are often bacteria
CONDITION ASSESSMENT
Common causative bacteria include Streptococcus
pneumoniae, Staphylococcus aureus, Legionella sp,
Chlamydia pneumonia and Moraxella catarralis.
Although other etiológica exist, as mentioned above, the
American Thoracic Society/Infectious Disease Society of
America Guidelines (ATS/IDS) for 2020 recommend
empirical treatment for bacterial pneumonia when a
person presents with signs and symptoms of pneumonia
Treatment options must target all likely organisms and
must also factor comorbidities such as heart failure as
well as liver disease or renal disease
CONFIRMATION OF DIAGNOSIS

All objective and subjective data presented above are

indicative of pneumonia
DRUG ASSESSMENT

IV Amoxicillin 1g tds
Amoxicillin is a beta lactam antibiotic with coverage of
organisms traditionally found in bacterial pneumonia,
including Strep pneumoniae, Staph aureus and H.
influenzae, as well as gran negative enteric bacteria that
may also be causative: Eschericia coli, Shigella sp,
Salmonella sp (Bobak et al., 2020; O’Dempsey et al.,
1994). In the ATS/IDS 2020 guidelines, treatment of
community acquired pneumonia with Comorbidities such
as chronic heart disease are managed with a beta-lactam
antibiotic in conjunction with a macrolide. This
medication, dosage and form used were appropriate for
the patient.
DRUG ASSESSMENT

Tab Azithromycin 500mg daily

Azithromycin, a macrolide antibiotic, is used in
pneumonia management for its coverage of atypical
causative organisms that contribute to pneumonia
infections in about 20% of cases(Can J Hosp Pharm,
2013); Legionella sp, Chlamydia pneumoniae and
Mycoplasma pneumoniae are examples. It is approved for
empiric management of community acquired pneumonia
in conjunction with a beta lactam antibiotic (Mandell et
al., 2007) and the dose used falls within the approved
range for use in CAP with comorbid conditions. The
patient, however, has been shown to have left branch
bundle block, which could contribute to arrhythmias.
DRUG ASSESSMENT

Tab Azithromycin 500mg bd (continued)

Azithromycin causes Q-T prolongation and is not ideal for
this patient. An appropriate alternative is doxycycline
100mg bd, which is also approved under the 2020
ATS/IDS guidelines for management of pneumonia
PLAN

Goals of treatment
1). To eradicate the causative
organisms
2) To improve patient’s
respiratory symptoms
3) To prevent reinfection
COUNSELLING

1) Patient was advised on side effects that may be

experienced with Azithromycin and amoxicillin - signs of
GI discomfort such as diarrhea and nausea
2) Patient was also asked to tell a doctor or a nurse
immediately he experienced signs of hypersensitivity -
such as increased difficulty in breathing, palpitations,
any undusual rashes on the skin
MONITORING
Medicati Efficacy Toxicity Test parameter Outcome
on

IV Resolving Hepatotoxicity, Liver function Patient’s

amoksicl symptoms of stomatitis, seizures, test, urine RE, pneumomia
av pneumonia crystalluria clinical symptoms
observation, resolved
auscultation

Tab Resolving QT prolongation, ECG, Liver Patient’s

Azithro symptoms of hepatotoxicity function test, pneumomia
mycin pneumonia (cholestasis), clinical symptoms
500mg Nausea, diarrhea, observation, resolved
hypersensitivity auscultation
reactions
REFERENCES

The British National Formulary, 80 th edition. The

Royal Phrmaceutical Society , London UK . Page 148,
484, 469
2013 ACCF/AHA Guideline for the Management of
Heart Failure: A Report of the American College of
Cardiology Foundation/American Heart Association
Task Force on Practice Guidelines
PLAN

Interventions

1) Recommend substitution of Tab Azithromycin 500mg

daily with Tab doxycycline 100mg bd
2) Counsel patient on various side effects that may be
anticipated with medications being used
3) Monitor the medications being administered to ensure
appropriate administration and effectiveness, as well as
to detect toxicity
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ACC/AHA 2005 Guideline Update for the Diagnosis and Management of

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MD, PhD, FACC, FAHA , Gary S. Francis, MD, FACC, FAHA , Theodore G.
Ganiats, MD , Mariell Jessup, MD, FACC, FAHA , Marvin A. Konstam, MD,
FACC , Donna M. Mancini, MD , Keith Michl, MD, FACP , John A. Oates,
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Yancy, MD, FACC, FAHA , Elliott M. Antman, TASK FORCE MEMBERS:,
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