How to respond to a classmates post for a case study Congestive Heart Failure (CHF) Solved
Case prompt: LV is a 72 with chronic stable CHF.
1. What medication(s) may worsen one with CHF, what meds for diabetes may need to be avoided in one with CHF and why?
Classmate’s post:
If you have CHF it is important to know which medication is safe to take. There are a few medications that should not be taken at all and some you can take with a little more frequent monitoring than normal. Nonsteroidal anti-inflammatory drugs (NSAIDs) are dangerous for CHF patients. Their effect is achieved by the reduction in synthesis of prostanoids. Inhibition of prostanoids is responsible for a substantial risk of adverse effects. The possibilities of blood pressure elevation and the development of congestive heart failure are widely recognized. Inhibition of prostanoid production in the kidney may reduce glomerular filtration and excretion of sodium and water. NSAIDs are therefore associated with risk of hypervolemia and worsening heart failure. The risk is increased in patients with impaired renal or cardiac function and it’s the highest if pre-existing congestive heart failure (CHF) is present, especially if controlled by diuretics (Varga et al, 2017).
Sulfonylureas such as glyburide and Thiazolidines such as actos could worsen CHF. Tzds can cause sodium retention as well as fluid retention and sulfonylureas are still know to worsen heart failure but the reasoning is unknown. Shortly after rosiglitazone and pioglitazone were marketed for clinical use, data appeared which indicated that edema and congestive heart failure were significant complications of TZD treatment of patients with diabetes mellitus. The magnitude of the problem was sufficiently important that the American Diabetes Association and the American Heart Association held a Consensus Conference to discuss and publish a Consensus Statement on “Thiazolidinedione Use, Fluid Retention, and Congestive Heart Failure Lebovitz, H.E, 2019).
Although it has been suggested that calcium channel blocking agents may be utilized as vasodilators in patients with congestive heart failure, these agents also have the potential to cause a deterioration in cardiac function because of their negative inotropic actions.
Stimulants are another medication that should be watched closely when given to patients with a history of CHF.
2. What are the two classes of diuretics are commonly used for CHF and why?
The two types are thiazides and loop diuretics.
Diuretics are considered currently to be the first‐line treatment for patients with chronic heart failure, irrespective of etiology, age, sex, and the individual characteristics of the patient, since they provide symptomatic relief. Diuretics increase sodium urinary excretion and decrease physical signs of fluid retention in patients with chronic heart failure.
3. What is the role and mechanism for ACEIs, ARBs, digoxin, and BBs in one with CHF
Angiotensin-converting enzyme inhibitors effectively lower the mean arterial blood pressure as well as systolic and diastolic blood pressure both in hypertensive and normotensive patients. Angiotensin-converting enzyme inhibitors (ACEIs) improve heart failure by decreasing afterload, preload, and systolic wall stress, which results in increased cardiac output. ACE inhibitors play an important role in promoting salt excretion by augmenting the renal blood flow and reducing aldosterone and antidiuretic hormone production. Apart from decreasing the afterload, ACEIs also reduce cardiac myocyte hypertrophy. in patients who cannot tolerate ACEI therapy due to an ACEI-induced cough or angioneurotic edema, ARB therapy is appropriate and suggested as an alternative. ARBs antagonize the effect of AII on AT1 receptors, and aldosterone antagonists block the effect of aldosterone ARBs are generally well tolerated and have a low incidence of side effects. The incidence of angioedema and cough with ARBs is less than with ACEIs because ARBs do not increase bradykinin levels though reports of rare cases of both exist with patients using ARBs. ARBs can cause hypotension and/or renal failure in patients whose arterial blood pressure or renal function is highly dependent on the RAAS. For this reason, these drugs are contraindicated in patients with bilateral renal artery stenosis or patients with heart failure who have hypotension. (Hill & Vaydia, 2022).
Digoxin is beneficial in patients with systolic heart failure, better known as heart failure with reduced ejection fraction (HFrEF), with an ejection fraction below 40%.
Digoxin has two principal mechanisms of action, which are carefully chosen depending on the indication: Positive Ionotropic: It increases the force of contraction of the heart by reversibly inhibiting the activity of the myocardial Na-K pump, an enzyme that controls the movement of ions into the heart. Digoxin induces an increase in intracellular sodium that will drive an influx of calcium in the heart and cause an increase in contractility. Cardiac output increases with a subsequent decrease in ventricular filling pressures (David & Shetty, 2022).
AV Node Inhibition: Digoxin has vagomimetic effects on the AV node. By stimulating the parasympathetic nervous system, it slows electrical conduction in the atrioventricular node, therefore, slowing sown the heart rate. The rise in calcium levels leads to prolongation of phase 4 and phase 0 of the cardiac action potential, thus increasing the AV node\’s refractory period. Slower conduction through the AV node carries a decreased ventricular response (David & Shetty, 2022).
Patients with chronic heart failure have prolonged sympathetic stimulation and subsequent worsening of the failing heart function. Beta-Blockers counteract the effects of prolonged sympathetic stimulation. Beta-blocker therapy results in the improvement of the left ventricular systolic and diastolic function, reversal remodeling, heart rate control, effective prevention of the malignant arrhythmias, and lowering of both cardiac afterload and preload in patients with chronic heart failure.
4. For all medications discussed please explain the monitoring parameters of efficacy and side effects.
When loop diuretics are prescribed for management of CHF, monitoring for relief can be efficient. Weighing a patient daily may be the most effective way to measure efficacy of medication. Once the patient is clinically euvolemic or at their dry weight the dose should be decreased to lowest dose tolerated to produce results. Side effects of these diuretics include hypokalemia and other electrolyte imbalances, renal issues, and hypotension (Colluci and Sterns, 2022).
The most common adverse effects of digoxin are dysrhythmias. Because serious dysrhythmias are a potential consequence of the usage of digoxin one should be monitored frequently for changes in heart rate as well as rhythm. If serious changes are noted the medication should be held (Rosenthal & Rosenjack, 2021). Patients on digoxin should also be monitored frequently for digoxin toxicity. Signs of digoxin toxicity include GI disturbances, arrhythmias as well as visual disturbances.
For patients on ACE Inhibitors and ARB’s, blood pressure should be monitored regularly. Systolic BP should be greater than 100 to avoid hypotension. Side effects also include, angioedema, and renal dysfunction. Patients on ACE Inhibitors frequently can show signs of a dry cough. When monitoring beta blockers, baseline and follow-up examinations of heart rate and EKG should be maintained. Signs and and symptoms of Heart Failure should be monitored, specifically fluid overload and bradycardia. . Side effects of beta blockers include increased airway resistance which can be dangerous to asthmatics. PAD, hyperkalemia, depression, fatigue, sexual dysfunction as well as weight gain (Podrid, 2022).
COLUCCI, W. (2021). Secondary pharmacologic therapy in heart failure with reduced ejection fraction (HFrEF) in adults.
David MNV, Shetty M. Digoxin. [Updated 2022 Sep 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/
Hill RD, Vaidya PN. Angiotensin II Receptor Blockers (ARB) [Updated 2022 Mar 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/
Lebovitz, H.E. Thiazolidinediones: the Forgotten Diabetes Medications. Curr Diab Rep 19, 151 (2019). https://doi.org/10.1007/
Podrid, P. J. (2020). Major side effects of beta blockers. UpToDate. Waltham (MA): UpToDate. Available at: https://www. uptodate. com/contents/major-side-
Varga Z, Sabzwari SRA, Vargova V. Cardiovascular Risk of Nonsteroidal Anti-Inflammatory Drugs: An Under-Recognized Public Health Issue. Cureus. 2017 Apr 8;9(4):e1144. doi: 10.7759/cureus.1144. PMID: 28491485; PMCID: PMC5422108.
MY RESPONSE TO CASE STUDY
Discussion 1 (Renee) G2: Thanks for this informative post about congestive heart failure. To begin with, patients with CCF take on average 6.8 prescription medications per day and this increases the chances of drug interactions (Marti et al., 2019). As mentioned, over-the-counter (OTC) drugs like NSAIDs can worsen CCF through their effects on the kidneys. Apart from NSAIDS, I would mention that antihypertensives like beta blockers and alpha-1-blockers also have a significant effect on CCF(Rosenthal & Burchum, 2020). Although recent studies demonstrate they are partly safe, they should be used with caution. It is good that you mentioned calcium channel blockers and the negative inotropic effect that makes them a threat to patients with CCF. Regarding antidiabetics that cause problems in CCF, I agree that sulfonylureas such as glyburide and Thiazolidines can worsen the disease. Still, on this topic, it is not until recently that metformin was approved for the management of diabetes in patients with CCF.
Diuretics commonly used for the management of heart failure include thiazides and loop diuretics. As you mentioned, these drugs are the first-line choice in all patients with CCF and thiazides are the first treatment of choice for individuals diagnosed with hypertension (Rosenthal & Burchum, 2020). A detailed explanation of the role and mechanism of ACEIs, ARBs, digoxin, and BBs in managing CCF is provided. I have learned something new about ARBs and how they relate to bilateral renal artery stenosis. I would add that ACE inhibitors are superior in managing CCF compared to ARBs because they have a greater vasodilatory effect through their action on bradykinin (Rosenthal & Burchum, 2020). Regarding the parameters of efficacy, I would go back to the goal of treatment which is to relieve symptoms and improve quality of life. As you mentioned, monitoring weight, fluid overload, and side effects of drugs are key.
References
Marti, C. N., Fonarow, G. C., Anker, S. D., Yancy, C., Vaduganathan, M., Greene, S. J., Ahmed, A., Januzzi, J. L., Gheorghiade, M., Filippatos, G., & Butler, J. (2019). Medication dosing for heart failure with reduced ejection fraction – opportunities and challenges. European Journal of Heart Failure, 21(3), 286–296. https://doi.org/10.1002/ejhf.1351
Rosenthal, L., & Burchum, J. (2020). Lehne’s Pharmacotherapeutics for Advanced Practice Nurses and Physician Assistants-E-Book. Elsevier Health Sciences
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