Heart failure

Clinical pharmacy‐1
Lab‐5
Fall 2021
  Heart Failure

HF is a complex clinical syndrome caused

by any structural or functional cardiac
disorder that impairs the ability of the
ventricle to fill with or eject blood.
 Types of HF
 Compensatory mechanism of HF
 Treatment algorithm for HF
 Parameters to be monitored for
each drug class
1‐ ACEI
 Blood pressure….. Hypotension
 Serum Creatinine & Potassium level… Hyperkalemia , Renal insufficiency

2‐ β‐BLOCKERS
 BP, HR, and symptoms of hypotension or bradycardia

3‐ Diuretics
 Monitor SCr and renal function to avoid acute kidney injury with
overdiuresis.
 Monitor and replace K especially with loop diuretics
 Parameters to be monitored for
each drug class
4‐ Aldosterone Antagonists
 Serum Creatinine & Potassium level
 Gynecomastia….(Eplerenone can be considered as an alternative to
spironolactone if gynecomastia is present)

5‐Nitrates and Hydralazine

 Headache & Hypotension

6‐Digoxin
 Serum concentrations should be less than 1 ng/mL
 Signs of toxicity generally include nausea, vomiting, vision changes
 Serum Creatinine & Potassium level
Case presentation

Mr AB is a 67‐year‐old man who was admitted to

the emergency department complaining of
increasing shortness of breath. He has woken on
each of the last two nights, struggling for breath.
On arrival at hospital and on subsequent
examination and review by the admitting doctor
the following information is obtained
History of presenting complaint:
o Shortness of breath and tiredness increasing over the last
two months. Is able to walk approximately 20 meters.
Past medical history:
Ischemic heart disease over 10 years
Myocardial infarction 1 year ago
Hypertension (10 years).
Social history:
The patient is a regular cigarette smoker (>30 per day) and
drinks approximately 35 units of alcohol per week.
Family history
No family history of cardiovascular disease
Drug history on admission
No known allergies. Prescribed drugs are listed in Table Q2
Signs and symptoms on examination
Patient was pale on examination.
_ Temperature 36.8°C
_ Blood pressure 105/60 mmHg
_ Heart rate 90 bpm, irregular
_ Swelling of ankles (SOA) – pitting to the knees
_ JVP +4 cm
_ Weight 97 kg (usually 85 kg)
_ CXR – cardiomegaly
_ Basal crackles in both lungs
_ ECG – normal.
Biochemistry results at admission
Na+ 132 mmol/L (135–145 mmol/L)
K+ 4.3 mmol/L (3.5–5.0 mmol/L)
Urea 17 mmol/L (0–7.5 mmol/L)
Creatinine 169 micromol/L (35–125 micromol/L)
Total cholesterol 3.9 mmol/L (<4 mmol/L)
Blood glucose 4.4 mmol/L (4–10 mmol/L)
Bilirubin 12 micromol/L (0–17 micromol/L)
ALT 30 units/L (0–50 units/L)
Alk phos 65 units/L (30–135 units/L)
Thyroid function tests were also taken and have all returned as being within
a normal range.
Full blood count found all parameters were normal and within range.
Diagnosis:

A preliminary diagnosis of acute heart failure is made

Q1‐ What signs and symptoms experienced by
this patient indicate that he has heart failure?
Does he have right‐ or left‐sided heart failure
or both? Explain your answer?
Symptoms are:
Shortness of breath (indicates lung congestion and therefore left‐sided heart failure)
tiredness/lethergy (+ only able to walk limited distance)
swelling of ankles and pitting to the knees (indicates right‐sided heart failure).
Signs are:
increasing weight due to increased fluid retention
cardiomegaly on CXR
basal crackles in both lungs (indicate fluid retention in the lungs due to left sided heart
failure)
increased JVP
increased urea and creatinine (indicates renal impairment).

 The patient has both left‐ and right‐sided heart failure as he is displaying
signs and symptoms such as swelling of the ankles and increased jugular
venous pressure (right‐sided heart failure) and lung congestion (left‐
sided heart failure).
Q2‐ What system is used to classify heart
failure according to severity of symptoms?
The New York Heart Association (NYHA) classification is a well‐accepted
classification of heart failure based on the severity of symptoms:
Class I – No symptoms with normal physical activity.
Class II – Slight limitation and shortness of breath on moderate to
severe exertion.
Class III – Marked limitation of activity, less than ordinary activity
causes Shortness of breath.
Class IV – Severe disability, dyspnea at rest, no physical activity
possible without discomfort.
Q3‐ What drug treatment should be initiated
for the immediate management of the edema
associated with the acute heart failure?
Diuretic therapy should be initiated for the acute
heart failure. An agent such as furosemide would be
appropriate. The aim of the furosemide treatment is
to relieve symptoms such as shortness of breath and
to make the patient more comfortable. A dose of
furosemide 40 mg twice daily (8am and 2pm) would
be appropriate as initial therapy.
Q4‐ What parameters should be monitored to
ensure the effectiveness of the drug treatment for
edema and to minimize toxicity?
1‐Blood pressure:
The aim is to ensure blood pressure is as near normal as Possible and to avoid a
precipitous drop in blood pressure. The healthcare Staff managing the patient’s
care should try and ensure that blood pressure is kept above 100/60 mmHg.
Blood pressure should be monitored regularly throughout the day, including
before furosemide dosing and a few hours after. In some cases continued
monitoring via electronic means may be considered, depending upon the
patient’s condition.
2‐Heart rate:
The aim is to keep as near normal as possible. Normal rate is around 70–80 bpm.
If over‐diuresis occurs, then rate may increase due to compensatory mechanisms.
3‐Weight:
The patient’s weight should be monitored on a daily basis to ensure that
excess fluid is removed. This will improve symptoms and make the patient
more comfortable. The aim is for a weight loss of no more than 1 kg per day.
Any more is likely to indicate over‐diuresis.
4‐Fluid balance:
The total amount of fluid the patient takes in (including any from drug
therapy) and excretes (urine) must be monitored. In the acute phase the aim
is to remove more than is taken in and to limit the patient’s fluid intake.
5‐Urea and electrolytes:
Sodium, potassium, urea and creatinine require close daily monitoring. The
aim is to normalize and to avoid, in particular, drops in electrolytes such as
sodium and potassium due to diuretic therapy. Other electrolytes such as
magnesium and calcium may need to be checked regularly.
Q5‐ What are the overall aims of drug
treatment in acute heart failure?
 Ensure that appropriate diuretic therapy is prescribed at a suitable
dose and frequency.
 Relieve congestion and to monitor the patient for improvement in
signs and symptoms of heart fluid retention such as shortness of
breath, swelling of the ankles and reduce jugular venous pressure.
 Monitor weight loss as a measure of fluid loss.
 Maintain blood pressure and heart rate within normal limits.
 Monitor urea and electrolytes and to ensure they remain within
normal ranges.
Q6‐ The patient’s symptoms stabilize over the initial
24 hours. What other class of drug treatment should
now be initiated at this stage for management of
chronic heart failure? Indicate a drug, starting dose
and any parameters that need monitoring.

• All patients with heart failure due to left ventricular systolic dysfunction
must be initiated on an ACE inhibitor. This should be initiated as soon as the
patient’s acute symptoms have been controlled at the appropriate dose and
then titrated up at short intervals to the target dose or maximum tolerated
dose. A suitable agent would be ramipril 2.5 mg once daily, which then could
be slowly titrated (e.g. approximately every two weeks) to the target of 10 mg
once daily or 5 mg twice daily. Parameters that require regular monitoring are
blood pressure, urea and electrolytes (particularly serum potassium) at drug
initiation then every week and after each dose increase until stable.
Q7‐What side‐effect can occur when first
initiating the treatment above and how can
this side‐effect be minimized?
• Profound first‐dose hypotension can occur when ACE inhibitors are
introduced to patients with heart failure. This effect may be
particularly pronounced if the patient is taking a high dose of a loop
diuretic. Temporary withdrawal of the loop diuretic could be
considered but is not appropriate in this case as it may cause rebound
pulmonary edema. Therefore in this case the steps are to initiate the
ACE inhibitor at low dose (e.g. ramipril 1.25 mg daily at night time
while the patient is lying down) and then to monitor blood pressure
hourly for the first 4 hours.
Q8‐What is the role of beta‐blockers in
heart failure?
• NICE guidelines state that beta‐blockers should be used in
patients with heart failure due to left ventricular systolic
dysfunction after ACE inhibitor regardless of whether symptoms
persist or not.
• Beta‐blockers have been shown to reduce total mortality,
hospitalization and improve left ventricular ejection fraction in
patients with mild, moderate and severe heart failure.
Furthermore, it protect against cardiac remodeling
Q9‐ What advice should be given to the
patient at discharge with regard to
lifestyle issues?
• The patient should be advised to follow standard advice with
regard to following a healthy, low‐fat diet, stopping smoking,
reducing his alcohol intake to within normal limits (<28 units per
week). In addition he needs to be advised regarding his fluid and
salt intake but the exact restrictions on these will depend on the
extent of his heart failure and symptoms.