Jeannine Costigan RN(EC) Nurse Practitioner Heart Function Clinic Case Study Jeannine Costigan RN(EC) Nurse Practitioner Heart Function Clinic

Mrs. N 77 y/o Vietnamese female Admitted for heart failure in 2009 PMHx: hypertension, renal insufficiency and type II diabetes (on OHA) for 6 years Meds on admit: Metformin 1 gram po BID, glyburide 10 mg po BID, Bisoprolol 10 mg po daily, HCTZ 25 mg po daily, Lipitor 40 mg po daily, Adalat XL 60 mg po daily.

Physical Exam: BP 180/100 mmHg, HR 56, 02 sats 88% on r/a, Crackles bilaterally, JVP 8 cm ASA, S4 on auscultation, mild edema. Laboratory Investigations: Cr 180 (CrCl 21 ml/min), Urea 10.4, HgbA1C 0.088, Na 132, K+ 3.2, hgb 122, trop 0.3(x3)

ECG: atrial flutter at 56. No ischemic changes ECG: atrial flutter at 56. No ischemic changes. No previous history of a-flutter. Chest x-ray: Pulmonary edema 2D echo: Preserved EF (60%), mild concentric LVH, RV normal but slightly thick, mild AS (AvA 1.5 cm2), RVSP 41 mmHg, mild TR.

Diuresed over the next 3 days Discharged home with Cr back to baseline of 153 Discharge medication: Lipitor 40 mg daily, bisoprolol 5 mg daily, Furosemide 40 mg po daily, Ramipril 10 mg po daily, Spironolactone 12.5 mg po daily and Coumadin.

RESPONDERS READY

How would you manage her diabetes Stop oral hypoglycemic agents and start insulin Stop Metformin and glyburide and start Diamicron

Referred to a local nephrologist. Creatinine 200, BUN 18.6 Urinary Albumin/Creatinine ratio 389 mg Alb/mmol Cr Microalbumin 2260 mg/L Physical exam: JVP 5 cm ASA, BP 188/100 mmHg

Management Questions RESPONDERS READY!

How would you manage her hypertension given her history of heart failure and worsening renal function? Stop ACE-I and consider another agent like Hydralazine? Continue ACE-I despite increased Cr and add another agent like Amlodipine?

Hydralazine, Minoxidil can increase LVH TREATMENT OF HYPERTENSION IN PATIENTS WITH LEFT VENTRICULAR HYPERTROPHY Hypertensive patients with left ventricular hypertrophy should be treated with antihypertensive therapy to lower the rate of subsequent cardiovascular events Vasodilators: Hydralazine, Minoxidil can increase LVH Left ventricular hypertrophy ACEI ARB, CCB Thiazide Diuretic - BB (if age below 60)* 11

TREATMENT OF HYPERTENSION IN ASSOCIATION WITH DIABETIC NEPHROPATHY THRESHOLD equal or over 130/80 mmHg and TARGET below 130/80 mmHg Addition of one or more of Long-acting CCB or Thiazide diuretic DIABETES with Nephropathy ACE Inhibitor or ARB IF ACEI and ARB are contraindicated or not tolerated, SUBSTITUTE • Long-acting CCB or • Thiazide diuretic 3 - 4 drugs combination may be needed If Creatinine over 150 µmol/L or creatinine clearance below 30 ml/min ( 0.5 ml/sec), a loop diuretic should be substituted for a thiazide diuretic if control of volume is desired 1. Persons with diabetes mellitus should be treated to attain systolic blood pressure of lower than130 mmHg (Grade C) and diastolic blood pressure of less than 80 mmHg (Grade A). (These target blood pressure levels are the same as the blood pressure treatment thresholds.) Combination therapy using two first-line agents may also be considered as initial treatment of hypertension (Grade B) if the SBP is 20 mmHg above the target or if DBP is 10 mmHg above the target. However caution should be exercised in patients in whom a substantial fall in blood pressure is more likely or poorly tolerated (e.g. elderly patients, patients with autonomic neuropathy). 2. For persons with cardiovascular or kidney disease, including microalbuminuria or with cardiovascular risk factors in addition to diabetes and hypertension, an ACE inhibitor or an ARB is recommended as initial therapy (Grade A). 3. For persons with diabetes and hypertension not included in the above recommendation, appropriate choices include (in alphabetical order): ACE inhibitors (Grade A), angiotensin receptor blockers (Grade B), dihydropyridine CCBs (Grade A) and thiazide/thiazide-like diuretics (Grade A). 4. If target blood pressures are not achieved with standard-dose monotherapy, additional antihypertensive therapy should be used. For persons in whom combination therapy with an ACE inhibitor is being considered, a dihydropyridine CCB is preferable to hydrochlorothiazide (Grade A). Monitor serum potassium and creatinine carefully in patients with CKD prescribed an ACEI or ARB 12

RESPONDERS READY

How would your medical management change if she had an EF <40%? Continue ACE-I and add hydralazine and nitrates. There would be no change to medical therapy Countdown 10

Non dihydropyridine CCB VII. TREATMENT OF HYPERTENSION WITH LEFT VENTRICULAR SYSTOLIC DYSFUNCTION • ACEI and Beta blocker • if ACEI intolerant: ARB Titrate doses of ACEI or ARB to those used in clinical trials Systolic cardiac dysfunction If additional therapy is needed: • Diuretic (Thiazide for hypertension; Loop for volume control) • for CHF class II-IV or post MI and selected patients with LV dysfunction (see notes): Aldosterone Antagonist If ACEI and ARB are contraindicated: Hydralazine and Isosorbide dinitrate in combination If additional antihypertensive therapy is needed: • ACEI / ARB Combination • Long-acting DHP-CCB (Amlodipine) Non dihydropyridine CCB Beta-blockers used in clinical trials were bisoprolol, carvedilol and metoprolol. 15

Mrs. N (Continued) Readmit in September 2011 with HF BP 178/78, HR 50 (a flutter) Creatinine stable at 180, urea 10, trop 0.4(x3) Required IV nitro initially for HF and BP control No evidence for angina by history Major issues with fluid and salt indiscretion Medication on admission: Norvasc 5 mg po daily, ECASA 81 mg, bisoprolol 5 mg po daily, Furosemide 40 mg daily, Ramipril 10 mg daily, warfarin and insulin.

Despite adequate diuresis BP remains difficult to control. SBP ranges between 180-220 mmHg Cardiologist switches from Ramipril to Coversyl and adds Aliskiren (Rasilez). Bisoprolol discontinued due to asymptomatic bradycardia Creatinine at discharge 180. Discharge med summary: ECASA 81, Aliskiren 150 po daily, Lipitor 20 mg po daily, Norvasc 10 mg po daily, Coversyl 8 mg po daily, Novolin 30/70 bid, Warfarin

RESPONDERS READY

The Bisoprolol should not have been discontinued as they are the cornerstone of HF therapy. Her bradycardia was asymptomatic. TRUE FALSE Countdown 10

Mrs. N Referred to Heart function clinic Weight had increased by 10 pounds Sodium intake high by diet history NYHA class III BP 150/88, JVP 8 cm ASA, bibasilar crackles Still volume overloaded but Cr 230, BUN 21.6 Med Review: Aliskiren 150 mg po od, Coversyl 8 mg po q hs, Norvasc 10 mg po od, Insulin, Furosemide 80 mg po daily.

RESPONDERS READY

How would you manage her volume status at this point? Give a dose of IV Furosemide in clinic and increase baseline Furosemide dose to 80 mg po BID. Hold Furosemide given increased creatinine and admit to hospital. Countdown 10

STRATEGIES FOR MANAGING DIURETIC RESISTANCE Additional diuretic such as metolazone PICC line for home IV Furosemide Ultrafiltration