Case 1. Case 2. What do you think about reducing or discontinuing some of the above now that his LVEF has normalized?

Transcription

1 Case 1 A primary care colleague inquires what to do with a patient (HFrEF in NSR) who has a digoxin level of 2.8ng/ml. Level was obtained at 10am, patient takes all medications at one time upon arising at 7am. Your options: A. Continue current dose B. Reduce dose to target a level < 1ng/ml and repeat level in 1-2 weeks C. Reduce dose to target a level < 1ng/ml and repeat level in 1-2 days D. Repeat level Case 2 A 68yowm with HFpEF, improved presents to clinic. After institution of GDMT three years ago his LVEF is now 49% (previously 30%). No symptoms and he feels well. Currently on carvedilol 25mg bid, lisinopril 40mg daily, spironolactone 25mg daily, digoxin 0.125mg daily, furosemide 20mg prn What do you think about reducing or discontinuing some of the above now that his LVEF has normalized? 1

2 Case 3 68 yo white male new to your clinic presents with a history of heart failure (EF 30%), AICD/PM, CAD (post MI 1999), HTN, Dyslipidemia, DM, PAD with intermittent claudication, CKD Currently, quite stable with no complaints. Able to do ADL without symptoms and no changes in medications in the last 18 months. No edema. No PND/Orthopnea. No dizziness or lightheadedness. No chest pain. Case 3 Medications: ASA 81mg daily, carvedilol 25mg bid, furosemide 80mg daily, KCL 20meq daily, enalapril 20mg bid, simvastatin 40mg qhs, digoxin 0.25mg daily, cilostazol 100mg bid BP 110/70mmHg, BUN/Cr 30/1.6mg/dl, Digoxin level 1.4ng/ml, K+ 4.8meq/L Do you want to make any changes? 2

3 Case 4 62yo white female with CKD, proteinuria, diabetes mellitus, hypertension, moderate LVH, obesity, and HFrEF (EF 35%), NYHA Class II Medications: metoprolol succinate SA 100mg daily, bumetanide 2mg daily, rosuvastatin 10mg daily, aspirin 81mg daily, digoxin 0.125mg every other day BUN/Cr 30/2.5mg/dl, K+ 4.8meq/L, BP 115/65mmHg, HR 55 bpm, EGFR 21ml/min/1.73m 2 Start and ACEi or an ARB? A. ACE inhibitor B. ARB C. Neither D. Both Case 4 BUN/Cr go from 30/2.5mg/dl to 32/3mg/dl A. Stop ACE inhibitor B. Continue ACE inhibitor C. Increase dose of ACE inhibitor D. Decrease diuretic E. Call your lawyer 3

4 Case 5 A 52 year old female with chronic heart failure with reduced ejection fraction (EF 15%) awaiting heart transplant. Patient is currently NYHA Class III/IV, and not responding with an adequate diuresis/relief of congestive symptoms despite furosemide 80mg bid. Patient has no prescription coverage. What may help overcome diuretic resistance? A. Review low salt diet B. Change to torsemide 40-80mg daily C. Have patient lay down after taking furosemide D. Instruct patient to take furosemide on an empty stomach E. A, C, & D Case 6 An 65 y/o woman with CAD, s/p anterior wall MI, with left ventricular dysfunction with an EF of 30%, and chronic kidney disease stage 3 (egfr 35 ml/min/1.73m 2 ) is found to be in heart failure during routine office visit. She has been taking ibuprofen for arthritic pain. Her medications include: furosemide 40 mg daily, lisinopril 5 mg daily, metoprolol tartrate 25 mg BID, aspirin 81 mg daily, atorvastatin 10 mg daily. Chest X-ray reveals pulmonary vascular congestion. She also has bilateral lower extremity edema. 4

5 Case 6 What actions would you take? A. Discontinue ibuprofen B. As the GFR becomes severe at 20 ml/min the dose of lisinopril should be decreased C. Furosemide reduces intravascular lung pressure and the dose should be increased D. Spironolactone 25 mg daily would be a good drug to add at this time E. A, B, & C F. A, C, & D G. A & C Case 6 What would you recommend for arthritic pain control? A. Nonacetylated salicylate (i.e. salsalate) B. Tramadol C. Naproxen D. Celecoxib E. A, B, or D F. Any of the above are acceptable 5

6 AHA Scientific Statement Use of Nonsteroidal Antiinflammatory Drugs Stepped approach to pharmacologic therapy for musculoskeletal symptoms in patients with known CVD or risk factors for IHD (in order of preference) Acetaminophen, ASA, tramadol, or narcotic analgesics (short term) Nonacetylated salicylates Non COX-2 selective NSAIDs NSAIDs with some COX-2 selectivity COX-2 selective NSAIDs Circulation. 2007;115: Drugs Associated with Adverse Effects in Heart Failure Patients Anti-Inflammatory Medications Glucocorticoids NSAIDs COX-2 Inhibitors TNF-α Antagonists Oral Hypoglycemics Thiazolidinediones Metformin Chemotherapeutic Agents Anthracyclines HER2 Antagonists Tyrosine Kinase Inhibitors VEGF inhibitors Antidepressants Clozapine Tricyclics Antiarrhythmic Drugs Others Minoxidil Cilostazol Anagrelide Testoserone Na-containing preparations 6

7 Case 7 A 73 year old male with chronic heart failure with preserved ejection fraction (EF 55%) presents for follow-up. Patient admits to dietary and medication noncompliance at times. He is currently NYHA Class II. He also complains of mild edema which resolves at night. PMH includes history of TIA, hypertension, moderate LVH, dyslipidemia, metabolic syndrome, obesity. Medications: diltiazem SA 240mg once daily, furosemide 20mg once daily, captopril 50mg three times daily, simvastatin 10mg qhs, aspirin 81mg once daily BP 160/70mmHg, repeat 155/65mmHg, HR75 bpm, BUN/Cr 15/1.2mg/dl, EGFR 63ml/min/1.73m 2 Case 7 Recommendations to optimize care? A. Stop diltiazem as he has heart failure B. Change furosemide to chlorthalidone C. Change captopril to lisinopril 40mg daily D. Increase furosemide to 20mg bid E. A & D F. B & C 7

8 Case 8 A 66 year old man has been followed for several years for CHF secondary to a nonischemic dilated cardiomyopathy. His echo reveals a dilated LV with an LVEF of 15%. His RV is also dilated and hypocontractile. His LA and RA are enlarged and he has 3+ TR. His blood pressure is 97/54 mmhg; his HR is 102 bpm; he has an elevated JVP with v waves, rales at both lung bases, and an easily heard S3. He has 3+ bilateral pitting edema of the legs. Case 8 His medicines include: captopril 25 mg tid; atenolol 25 mg daily; isosorbide dinitrate 10 mg tid; ASA 325 mg; furosemide 20 mg po daily; KCl 20 meq daily. He drinks two martinis every night before dinner. Which of the following changes in this patient s regimen might improve this man s symptoms? A. Increased dose of furosemide B. Addition of spironolactone C. Change BB from atenolol D. Addition of metolazone E. Addition of ARB such as losartan 8

9 Case 9 55yo black female in clinic with a history of ischemic cardiomyopathy, hypertension, heart failure with reduced ejection fraction (25%) Despite titration of furosemide over the last month she has continued to gain weight, persistent edema (2+), and experiences dyspnea with less than ordinary activity Case 9 Medications: furosemide 80mg bid, carvedilol 12.5mg bid, lisinopril 40mg daily, hydralazine 50mg TID, ISDN 40mg tid, potassium chloride 20meq bid, aspirin 81mg daily Pertinent findings: BP 115/65mmHg, HR 65 bpm, BUN/Cr 25/1.6mg/dl (baseline ), K+ 4.8meq/L, EGFR 43ml/min/1.73m 2 Your options: A. Switch to brand name furosemide B. Increase furosemide to 120mg qam and 80mg qpm C. Change to furosemide oral solution for better absorption D. Add metolazone 2.5mg po daily E. Switch to torsemide 20mg daily 9