How would you classify her heart failure?
According to the New York Heart Association (NYHA) Classification, the presenting patient would be classified as a class II, which is described as a patient who experiences slight limitation of physical activity, who is comfortable at rest, and ordinary physical activity results in fatigue, palpation, or dyspnea (American Medical Association, 2019). It is indicated that this patient has trouble breathing when she walks 2-3 blocks; class III would be appropriate if the patient experienced marked limitation of physical activity, but without improvement or change in medication regimen, the patient may soon present in class III. The American College of Cardiology Foundation/American Heart Association (ACCF/AHA) staging system complements the NYHA classification. According to the ACCF/AHA, the presenting patient would be a stage C, which pertains to patients with structural heart disease with current or past symptoms of heart failure, such as shortness of breath and reduced exercise tolerance (Dumitru & Baker, 2018).
What changes (modifications, additions, deletions) to her medications do you recommend that will:
According to the 2017 ACCF/AHA Guidelines for the Management of Heart Failure, step 1 of guideline-directed medical therapy (GDMT) for heart failure NYHA class II and III patients includes an ACEi or an ARB for blood pressure management and a beta-blocker, plus diuretics as needed (Yancy et al., 2017). Step 2 of this algorithm includes various suggestions based on certain patient scenarios, however, before moving onto step 2, the patient should have a medication regimen that is optimized by step 1. Verampil, a calcium-channel blocker, should be discontinued and an ACEi or an ARB should be initiated, along with a beta-blocker. Both ACEi’s and ARBs have been shown to decrease HF progression, hospitalizations, and mortality for asymptomatic and symptomatic HF patients, with ARBs being implemented over ACEi for patients who are intolerant to ACEi due to cough or angioedema (Yancy et al., 2017). Additionally, combination therapy with hydralazine and isosorbide dinitrate as add-on therapy to an ACEi or an ARB, or instead of if she cannot tolerate an ACEi or an ARB, would be appropriate for this patient since it is indicated that she is African American and this population is predisposed to having an imbalance of nitric oxide production (Chisholm-burns et al., 2019). After successful toleration of an ACEi or an ARB, ACCF/AHA guidelines indicate that for patients who can tolerate an ACEi or an ARB with chronic, symptomatic heart failure with reduced injection fraction (HFrEF) who are NYHA class II or III, replacement of the ACEi or ARB by an ARNI is recommended to further reduce overall hospitalization, morbidity, and mortality (Yancy et al., 2017). The approved ARNI for a symptomatic HFrEF patient is valsartan/sacuvitril; it should be noted that this medication should not be administered concomitantly with ACEi or within 36 hours of the last ACEi dose (Yancy et al., 2017). The patient should also be prescribed a GDMT beta-blocker such as bisoprolol, carvedilol, or metoprolol succinate (Yancy et al., 2017). According to AACF/AHA guidelines, patients with HFrEF and HTN should have their GDMT titrated to attain SBP <130 mm Hg (Yancy et al, 2017). Substitution of HCTZ for this patient with a loop diuretic, such as furosemide, bumetanide, or torsemide would be beneficial since the patient is experiencing bilateral edema and requires an elevated head of bed when sleeping due to breathing difficulties (Chisholm-burns et al., 2019) . Diuretics are useful for symptom management for relief of congestion and maintaining euvolemia (Chisholm-burns et al., 2019) Hypertension/Heart Failure Discussion Essays.
Impact long term outcomes?
The goal of pharmacologic therapy for this patient is ultimately to improve quality of life and prolong survival by reducing heart failure progression, preventing hospitalization, and reducing symptoms. This can be accomplished through measurable outcomes such as achieving SBP of <130 mm Hg and achieving euvolemia and therefore reducing edema and dyspnea. Increasing EF would also be a desirable outcome of optimized medication therapy.
What monitoring parameters do you recommend?
According to Chisholm-burns et al. (2019), major outcome parameters include monitoring of volume status, exercise tolerance, overall symptoms/ quality of life, adverse drug reactions, and disease progression/ cardiac function. Monitoring of medication adverse effects is important, such as monitoring for cough, angioedema, renal dysfunction, hypotension, and hyperkalemia wi
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