1) According to the ACC/AHA Guidelines,
ACC/AHA 2017 guideline places ML at stage C heart failure (Yancy et al., 2017). Pertinent positives to classifying ML at
stage C are:
HPI: 72-year-old AA, female c/o SOB for the last two months, SOB is worse with activity, wakes her up at night, resolved
with using 3 pillows, reports lower leg edema, feels lightheaded and faint when going up the stairs
PMH: HTN, MI in 2010- cardiac stent placement in 2010
Family Hx: father died of a heart attack; one brother died of a heart attack
ROS: lightheaded and faint with exertion. Shortness of breath with exertion + Orthopnea + leg and ankle swelling x 1
week. Non-compliant with medications for the last 6 months.
Physical: Obese, BP 148/86, inspiratory crackles, S2 split during expiration. An S4 is noted at the apex; systolic murmur
noted at the right upper sternal border without radiation to the carotids. 2+ pitting edema to her knees noted bilaterally.
Echo- LVEF 39% moderate dysfunction (American College of Cardiology, 2019)
BNP - 682 pg/ml – (Liu et al., 2015)
2) According to the ACC/AHA Guidelines,
The goal for ML is to decrease preload and afterload to reduce s/s of HF. Along with improving patient’s survival rates
(Inamdar & Inamdar, 2016). I will be monitoring ML very carefully according to Yancy, 2017 patients should be started on
the lower doses and increased as needed or for symptom relief.
Losartan-ARB- The rationale of prescribing an ARB is to improve the survival rate by causing vasodilation by
neurohormonal modification (Yancy et al., 2017). The reason for me to start with an ARB is that since ML is AA and
already non-complaint most patients who are on an ACE inhibitor may have unwanted side effects such as a cough and
angioedema.
Metoprolol succinate-Beta blockers- help control the ventricular rate and prevent arrhythmias by also providing
neurohormonal modifications (Yancy et al., 2017).
Spironolactone-Diuretics- The reason for prescribing a diuretic is to reduce fluid volume, but doing this it will help reduce
the edema in her lower legs and provide symptom relief (Bahit, Kockar, & Granger, 2018)
3) Given the patient’s history of MI
Aspirin-Antiplatelet therapy- aspirin is used to thin the blood to prevent blood clots from forming which can lead to a heart
attack or a stroke (Switaj, Christensen, & Brewer, 2017)
Lipitor- HMG-COA reductase inhibitor (statin)This is to reduce atherosclerosis from building up on the vessel’s walls
(Switaj, Christensen, & Brewer, 2017)
4) Write the complete prescriptions using the prescription writing format.
Metoprolol Succinate 12.5 mg tablet
Disp: #30
Sig: 1 tablet by mouth once a day
RF: 0
(Yancy et al., 2017).
Losartan 25mg
Disp: #30
Sig: 1 tablet by mouth once a day
RF: 0
(Yancy et al., 2017).
Spironolactone 12.5mg
, Disp: # 30
Sig: 1 tablet by mouth once a day recommended in the AM
RF:0
(Yancy et al., 2017).
Lipitor 10mg
Disp: #30
Sig: 1 tablet by mouth at night
RF: 3
(Switaj, Christensen, & Brewer, 2017)
Aspirin 81 mg
Disp: #30
Sig: 1 tablet by mouth once a day
RF: 1
(Switaj, Christensen, & Brewer, 2017)
I would like ML to follow-up with me in two weeks to evaluate s/s, edema, and medication compliance. In two weeks if
symptoms worsen or do not improve referral to cardiology may be needed. Depending on compliance patient may even
need to be sent to the ER.
American College of Cardiology. (2019). Left Ventricular Ejection Fractions LVEF Assessment. Retrieved September 8,
2019, from https://www.acc.org/tools-and-practice-support/clinical-toolkits/heart-failure-practice-solutions/left-ventricular-
ejection-fraction-lvef-assessment-outpatient-setting
Bahit, M., Kockar, A., & Granger, C. (2018). Post-myocardial infarction heart failure. JACC: Heart Failure, 6(3), 179-186.
Inamdar, A. A., & Inamdar, A. C. (2016). Heart Failure: Diagnosis, Management and Utilization. Journal of clinical
medicine, 5(7), 62. doi:10.3390/jcm5070062
Liu, Y., He, Y. T., Tan, N., Chen, J. Y., Liu, Y. H., Yang, D. H., … Chen, P. Y. (2015). Preprocedural N-terminal pro-brain
natriuretic peptide (NT-proBNP) is similar to the Mehran contrast-induced nephropathy (CIN) score in predicting CIN
following elective coronary angiography. Journal of the American Heart Association, 4(4), e001410.
doi:10.1161/JAHA.114.001410
Switaj, T., Christensen, S., & Brewer, D. (2017). Acute coronary syndrome: current treatment. American Family
Physician, 95(4), 232-240.
Yancy, C. W., Jessup, M., Bozkurt, B., Butler, J., Casey, D. J., Colvin, M. M., & ... Westlake, C. (2017). 2017
ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of
the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the
Heart Failure Society of America. Journal of The American College of Cardiology, 70(6), 776-803.
doi:10.1016/j.jacc.2017.04.025
o
Collapse SubdiscussionMarie Mompoint
Marie Mompoint
Sep 10, 2019Sep 10 at 8:35pm
Manage Discussion Entry
ACC/AHA 2017 guideline places ML at stage C heart failure (Yancy et al., 2017). Pertinent positives to classifying ML at
stage C are:
HPI: 72-year-old AA, female c/o SOB for the last two months, SOB is worse with activity, wakes her up at night, resolved
with using 3 pillows, reports lower leg edema, feels lightheaded and faint when going up the stairs
PMH: HTN, MI in 2010- cardiac stent placement in 2010
Family Hx: father died of a heart attack; one brother died of a heart attack
ROS: lightheaded and faint with exertion. Shortness of breath with exertion + Orthopnea + leg and ankle swelling x 1
week. Non-compliant with medications for the last 6 months.
Physical: Obese, BP 148/86, inspiratory crackles, S2 split during expiration. An S4 is noted at the apex; systolic murmur
noted at the right upper sternal border without radiation to the carotids. 2+ pitting edema to her knees noted bilaterally.
Echo- LVEF 39% moderate dysfunction (American College of Cardiology, 2019)
BNP - 682 pg/ml – (Liu et al., 2015)
2) According to the ACC/AHA Guidelines,
The goal for ML is to decrease preload and afterload to reduce s/s of HF. Along with improving patient’s survival rates
(Inamdar & Inamdar, 2016). I will be monitoring ML very carefully according to Yancy, 2017 patients should be started on
the lower doses and increased as needed or for symptom relief.
Losartan-ARB- The rationale of prescribing an ARB is to improve the survival rate by causing vasodilation by
neurohormonal modification (Yancy et al., 2017). The reason for me to start with an ARB is that since ML is AA and
already non-complaint most patients who are on an ACE inhibitor may have unwanted side effects such as a cough and
angioedema.
Metoprolol succinate-Beta blockers- help control the ventricular rate and prevent arrhythmias by also providing
neurohormonal modifications (Yancy et al., 2017).
Spironolactone-Diuretics- The reason for prescribing a diuretic is to reduce fluid volume, but doing this it will help reduce
the edema in her lower legs and provide symptom relief (Bahit, Kockar, & Granger, 2018)
3) Given the patient’s history of MI
Aspirin-Antiplatelet therapy- aspirin is used to thin the blood to prevent blood clots from forming which can lead to a heart
attack or a stroke (Switaj, Christensen, & Brewer, 2017)
Lipitor- HMG-COA reductase inhibitor (statin)This is to reduce atherosclerosis from building up on the vessel’s walls
(Switaj, Christensen, & Brewer, 2017)
4) Write the complete prescriptions using the prescription writing format.
Metoprolol Succinate 12.5 mg tablet
Disp: #30
Sig: 1 tablet by mouth once a day
RF: 0
(Yancy et al., 2017).
Losartan 25mg
Disp: #30
Sig: 1 tablet by mouth once a day
RF: 0
(Yancy et al., 2017).
Spironolactone 12.5mg
, Disp: # 30
Sig: 1 tablet by mouth once a day recommended in the AM
RF:0
(Yancy et al., 2017).
Lipitor 10mg
Disp: #30
Sig: 1 tablet by mouth at night
RF: 3
(Switaj, Christensen, & Brewer, 2017)
Aspirin 81 mg
Disp: #30
Sig: 1 tablet by mouth once a day
RF: 1
(Switaj, Christensen, & Brewer, 2017)
I would like ML to follow-up with me in two weeks to evaluate s/s, edema, and medication compliance. In two weeks if
symptoms worsen or do not improve referral to cardiology may be needed. Depending on compliance patient may even
need to be sent to the ER.
American College of Cardiology. (2019). Left Ventricular Ejection Fractions LVEF Assessment. Retrieved September 8,
2019, from https://www.acc.org/tools-and-practice-support/clinical-toolkits/heart-failure-practice-solutions/left-ventricular-
ejection-fraction-lvef-assessment-outpatient-setting
Bahit, M., Kockar, A., & Granger, C. (2018). Post-myocardial infarction heart failure. JACC: Heart Failure, 6(3), 179-186.
Inamdar, A. A., & Inamdar, A. C. (2016). Heart Failure: Diagnosis, Management and Utilization. Journal of clinical
medicine, 5(7), 62. doi:10.3390/jcm5070062
Liu, Y., He, Y. T., Tan, N., Chen, J. Y., Liu, Y. H., Yang, D. H., … Chen, P. Y. (2015). Preprocedural N-terminal pro-brain
natriuretic peptide (NT-proBNP) is similar to the Mehran contrast-induced nephropathy (CIN) score in predicting CIN
following elective coronary angiography. Journal of the American Heart Association, 4(4), e001410.
doi:10.1161/JAHA.114.001410
Switaj, T., Christensen, S., & Brewer, D. (2017). Acute coronary syndrome: current treatment. American Family
Physician, 95(4), 232-240.
Yancy, C. W., Jessup, M., Bozkurt, B., Butler, J., Casey, D. J., Colvin, M. M., & ... Westlake, C. (2017). 2017
ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of
the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the
Heart Failure Society of America. Journal of The American College of Cardiology, 70(6), 776-803.
doi:10.1016/j.jacc.2017.04.025
o
Collapse SubdiscussionMarie Mompoint
Marie Mompoint
Sep 10, 2019Sep 10 at 8:35pm
Manage Discussion Entry
