chronic care integration for endemic ncds.pdf - ncd alliance

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the pih guide to

Chronic Care Integration for Endemic Non-Communicable Diseases

rwanda edition

the pih guide toChronic Care Integration for Endem

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Partners In Health

Harvard Medical School Department of Global Health and Social Medicine Program in Global Non-Communicable Disease and Social Change

Brigham and Women’s Hospital Division of Global Health Equity

Partners In Health is a 501(c)3 nonprofit corporation based in Boston, Massachusetts. Established in 1987, PIH is committed to making a preferential option for the poor by working with sister organizations to improve the health and well-being of people living in poor communities. To this end, PIH provides technical and financial assistance, medical supplies, and administrative support to partner projects in Haiti, PerZu, Russia, Rwanda, Lesotho, Malawi, Mexico, Guatemala, Burundi, Kazakhstan, the Dominican Republic, and the United States. The goal of these partnerships is neither charity nor development but rather “pragmatic solidarity”— a commitment to struggle alongside the destitute sick and against the economic and political structures that cause and perpetuate poverty and ill health. Partners In Health is a!liated with the Division of Social Medicine at Harvard Medical School and the Division of Global Health Equity at the Brigham and Women’s Hospital.

More information on Partners In Health can be found at our web site: www.pih.org

the pih guide to


rwanda edition

Partners In Health



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s66666

About the Cover!"#$%&'()*#%)+#',&*-)#$.')*'$'/012345'-"3.)+'6$+).)#7'#8$#'*)#*'&9'$':&"92#$)9#&-')9'9&%#84%9';<$95$=*'!"%4%$'()*#%)+#>'?9'$55)#)&9'#&'*4%@)9A'#84'5)*#%)+#=*'B01C111'-4&-.4C'#84':$D&%)#7'&6'<8&:'*#)..'*"%@)@4'&9'$3&"#'$'5&..$%'$'5$7C'!"#$%&'<)..'$.*&'*4%@4'$*'$'9$#)&9$.'#4$+8)9A'8&*-)#$.'$95'+.)9)+$.'+49#4%'&6'4E+4..49+4>'F45'37'G$%#94%*'?9',4$.#8C')9'+&..$3&%$#)&9'<)#8'#84';<$95$9'A&@4%9:49#C'#84'8&*-)#$.'<$*'3").#'37'B011':49'$95'<&:49'6%&:'#84'.&+$.'+&::"9)#7'"*)9A'.&+$.':$#4%)$.*>'H8)*'<&%.52+.$**'6$+).)#7'<$*')9$"A"%$#45'&9'I$9"$%7'JK#8C'J1//>'L#'#84')9$"A"%$#)&9'+4%4:&97C';<$95$9'G%4*)549#'G$".'M$A$:4'*$)5C'N!"#$%&')*':&%4'#8$9'$'8&*-)#$.>'?#')*'$'"9)O"4'*#&%7'&6'4E+4-#)&9$.'-4&-.4'<)#8'#84'54*)%4'#&'*44'-&*)#)@4'+8$9A4')9'#84'<&%.5'$95')9'+&::"9)#)4*'.)P4'#84'&94'8&*#)9A'"*'

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contributors and acknowledgements

Editor-in-ChiefT494'!"P8:$9C'R(C'G8(

Principal AuthorsL.)+4'M)554%C'R(C'RG,'T494'M<$9C'R('T494'!"P8:$9C'R(C'G8(

Managing EditorL.)+4'M)554%C'R(C'RG,

Special ContributorsU%)+'M%$P$"4%C'R(C'G8('VS8$-#4%'JW'G$..)$#)@4'S$%4XI&*4-8'R"+":3)#*)C'R('$95';$.-8'R&%#&9'!&.:$9'???C'R('VS8$-#4%'0W'S$%5)$+'Y"%A4%7XL95%4$'!%$"9C'R('VS8$-#4%'ZW';49$.'[$)."%4XS8$%.&##4'!$@":$C'R('$95'L9$95'\$)57$C'R('VS8$-#4%']W'()$34#4*X

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iv chronic care integration for endemic non-communicable diseases

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table of contents

foreword xxiii;464%49+4*' EE)))

abbreviations xxv

chapter 1Integration of Chronic CareServices in Rwanda 1/>/' H84'F&9A'H$).'&6'U954:)+'`&92S&::"9)+$3.4'()*4$*4*')9';<$95$' /

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chapter 2Palliative Care and Chronic Care 17J>/' ,)*#&%7'$95'G8).&*&-87'&6'G$..)$#)@4'S$%4'U66&%#*')9''

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vi chronic care integration for endemic non-communicable diseases

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chapter 3Role of Community Health Workers, Family Planning, Mental Health, and Social Services in the Treatment of Chronic Disease 33B>/' S&::"9)#7',4$.#8'_&%P4%*' BB

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chapter 4Heart Failure 39

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table of contents vii

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viii chronic care integration for endemic non-communicable diseases

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chapter 5Cardiac Surgery Screening, Referral, Anticoagulation, and Postoperative Management 1070>/' ,)*#&%7'&6'S$%5)$+'Y"%A4%7')9';<$95$' /1]

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table of contents ix

0>d' H)#%$#)9A'_$%6$%)9'H84%$-7' /Jd

0>/1' (%"A'Y"--.7'$95'G$#)49#'R&9)#&%)9A' /B/

0>//' ($9A4%*'&6'L9#)+&$A".$#)&9' /BJ

chapter 6Chronic Kidney Disease 135Z>/' U#)&.&A7'&6'S8%&9)+'M)5947'()*4$*4')9';"%$.';<$95$' /B0

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chapter 7Diabetes 153

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x chronic care integration for endemic non-communicable diseases

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chapter 8Hypertension 187g>/' S.)9)+'$95'S&::"9)#72!$*45',7-4%#49*)&9'Y+%449)9A' /gd

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table of contents xi

g>]' [&..&<2a-'H%4$#:49#'6&%',7-4%#49*)&9' J10g>]>/' R$9$A4:49#'&6'_4..2S&9#%&..45',7-4%#49*)&9'&9''

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g>g' ,7-4%#49*)&9')9'G%4A9$9+7' J1Zg>g>/' ,7-4%#49*)&9')9'U$%.7'G%4A9$9+7'VS8%&9)+',7-4%#49*)&9X' J/1g>g>J' ,7-4%#49*)&9')9'F$#4%'G%4A9$+7'VT4*#$#)&9$.''

,7-4%#49*)&9'$95'G%44+.$:-*)$X' J//g>g>B' ;4+&A9)#)&9'$95'R$9$A4:49#'&6'U:4%A49#'S&95)#)&9*' J//g>g>K' Y+%449)9A'6&%'G%44+.$:-*)$' J//g>g>0' H%4$#:49#'&6'G%44+.$:-*)$'L++&%5)9A'#&''

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chapter 9Rheumatic Heart Disease Prevention 217d>/' G%4@49#)&9'&6'L+"#4';84":$#)+'[4@4%W'R$9$A4:49#''

&6'Y&%4'H8%&$#' J/]

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chapter 10Chronic Respiratory Disease 235/1>/' H84'!"%549'&6'S8%&9)+';4*-)%$#&%7'()*4$*4')9';"%$.';<$95$' JB0

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xii chronic care integration for endemic non-communicable diseases

/1>K' [&..&<2a-'R$9$A4:49#'&6'L*#8:$' JK]

/1>0' !%&9+8)4+#$*)*' JKd

chapter 11Epilepsy Forthcoming

epilogue 255

appendix aEssential Equipment and Medicines 257L>/' U**49#)$.'UO")-:49#' J0]

L>J' U**49#)$.'R45)+)94*' J0]

appendix bCost Models 261!>/' Y"::$%7'&6'b-4%$#)&9$.'S&*#'R&54.*' JZ/!>J' S$%5)&:7&-$#87' JZJ

!>J>/' S&*#'?9-"#*' JZJ!>J>J' L99"$.';4A):49'S&*#*'G4%'G$#)49#' JZJ!>J>B' G&-".$#)&9'LA4'()*#%)3"#)&9'$95'S$*42[)95)9A''

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!>B' S$%5)$+'Y"%A4%7' JZB!>B>/' S&*#'?9-"#*' JZB

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table of contents xiii

!>Z' ,7-4%#49*)&9'S&*#'R&54.*' JZg!>Z>/' S&*#'?9-"#*' JZg!>Z>J' L99"$.';4A):49'S&*#*'G4%'G$#)49#.' JZg!>Z>B' G&-".$#)&9'LA4'()*#%)3"#)&9'$95'S$*42[)95)9A' JZd!>Z>K' H&#$.'R$%A)9$.'S&*#*'G4%'S$-)#$' JZd

!>]' S8%&9)+';4*-)%$#&%7'()*4$*4'S&*#'R&54.*' J]1!>]>/' S&*#'?9-"#*' J]1!>]>J' L99"$.';4A):49'S&*#*'G4%'G$#)49#' J]1!>]>B' G&-".$#)&9'LA4'()*#%)3"#)&9'$95'S$*42[)95)9A' J]1!>]>K' H&#$.'R$%A)9$.'S&*#*'G4%'S$-)#$' J]/

!>g' U-).4-*7'S&*#'R&54.*' J]/!>g>/' S&*#'?9-"#*' J]/!>g>J' L99"$.';4A):49'S&*#*'G4%'G$#)49#' J]/!>g>B' G&-".$#)&9'()*#%)3"#)&9'$95'S$*42[)95)9A' J]/!>g>K' H&#$.'R$%A)9$.'S&*#*'G4%'S$-)#$' J]J

appendix cIndicators for Monitoring and Evaluation 271S>/' ,4$%#'[$)."%4'$95'G&*#2S$%5)$+'Y"%A4%7'[&..&<2a-' J]/

S>J' S$%5)$+'Y"%A)+$.';464%%$.'$95'S$*4'Y4.4+#)&9' J]B

S>B' ;49$.'[$)."%4' J]K

S>K' ()$34#4*' J]0

S>0' ,7-4%#49*)&9' J]]

S>Z' S8%&9)+';4*-)%$#&%7'()*4$*4' J]g

S>]' U-).4-*7' Jg1

appendix dForms 281(>/' ?9#$P4'[&%:*' Jg/

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xiv chronic care integration for endemic non-communicable diseases

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table of contents xv

[?Ta;U'Z>B' ,75%&94-8%&*)*'&9'a.#%$*&"95' /KK

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xvi chronic care integration for endemic non-communicable diseases

Tables

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chapter 4HL!FU'K>/' S$"*4*'&6',4$%#'[$)."%4';4-&%#45'37'Y4.4+#45''

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table of contents xvii

HL!FU'K>/0' R&%#$.)#72;45"+)9A'R45)+$#)&9*'6&%'S$%5)&:7&-$#87' Z]HL!FU'K>/Z' ()A&E)9'(&*)9A' ]BHL!FU'K>/]' L9#)87-4%#49*)@4*'6&%',7-4%#49*)@4',4$%#'()*4$*4' ]ZHL!FU'K>/g' R45)+$#)&9*'#&';45"+4',4$%#';$#4')9'R)#%$.'Y#49&*)*' g1HL!FU'K>/d' R45)+$#)&9*'6&%'\$.@".$%iS&9A49)#$.',4$%#'()*4$*4' g0HL!FU'K>J1' S.)9)+$.'G%4*49#$#)&9'&6';)A8#2Y)545',4$%#'[$)."%4' g]HL!FU'K>J/' S$"*4*'&6';)A8#2Y)545',4$%#'[$)."%4' ggHL!FU'K>JJ' H%4$#:49#'&6'H"34%+".&"*'G4%)+$%5)#)*')9'L5".#*' dJHL!FU'K>JB' S.)9)+'[&..&<2a-'Y+845".4'6&%',4$%#'[$)."%4'G$#)49#*' dZ

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chapter 6HL!FU'Z>/' S$"*4*'&6'U952Y#$A4';49$.'()*4$*4')9'Y"32Y$8$%$9''

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chapter 7HL!FU']>/' ()$34#4*'()$A9&*)*W'!.&&5'Y"A$%'R4$*"%4:49#''

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xviii chronic care integration for endemic non-communicable diseases

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chapter 9HL!FU'd>/' S.)9)+$.'(4+)*)&9';".4*'6&%'H%4$#:49#'&6'G8$%79A)#)*' JJ1

table of contents xix

HL!FU'd>J' L9#)3)&#)+';4A):49*'6&%'Y#%4-#&+&++$.'G8$%79A)#)*''VL5".#*'$95'L5&.4*+49#*'(&*)9AC'_4)A8#' 'J]'PAX' JJJ

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chapter 10HL!FU'/1>/' U@$."$#)&9'&6'L*#8:$'L##$+P'Y4@4%)#7'VL5$-#45'6%&:'

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xx chronic care integration for endemic non-communicable diseases

Protocols

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table of contents xxi

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xxiv chronic care integration for endemic non-communicable diseases

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References

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chapter 1Integration of Chronic Care Services in Rwanda

1.1 The Long Tail of Endemic Non-Communicable Diseases in Rwanda

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2 chronic care integration for endemic non-communicable diseases

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TABLE 1.1 Burden of Non-Communicable Diseases in Rwanda Linked to Conditions of Poverty

Condition Risk factors related to poverty

Hematology and oncology4-7

Cervical cancer, gastric cancer, lymphomas, Karposi’s sarcoma, hepatocellular carcinoma

HPV, H. Pylori, EBV, HIV, Hepatitis B

Breast cancer, CML Idiopathic, treatment gap

Hyperreactive malarial splenomegaly, hemoglobinopathies

Malaria

Psychiatric8 Depression, psychosis, somatoform disorders

War, untreated chronic diseases, undernutrition

Schizophrenia, bipolar disorder Idiopathic, treatment gap

Neurological9-11 Epilepsy Meningitis, malaria

Stroke Rheumatic mitral stenosis, endocarditis, malaria, HIV

Cardiovascular12-14 Hypertension Idiopathic, treatment gap

Pericardial disease Tuberculosis

Rheumatic valvular disease Streptococcal diseases

Cardiomyopathies HIV, other viruses, pregnancy

Congenital heart disease Maternal rubella, micronutrient deficiency, idiopathic, treatment gap

Respiratory14,15 Chronic pulmonary disease Indoor air pollution, tuberculosis, schisto-somiasis, treatment gap

Renal16 Chronic kidney disease Streptococcal disease

Endocrine17 Diabetes Undernutrition

Hyperthyroidism and hypothyroidism Iodine deficiency

Musculoskeletal18,19 Chronic osteomyelitis Bacterial infection, tuberculosis

Musculoskeletal injury Trauma

Vision20 Cataracts Idiopathic, treatment gap

Refractory error Idiopathic, treatment gap

Dental21 Caries Hygiene, treatment gap

chapter!1 | integration of chronic care services in rwanda 3

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TABLE 1.2 Leading Causes of Death and Disability in Rwanda in Disability-Adjusted Life Years (DALYs)24

Disease DALYs (’000)

Fraction of total DALYs

Lower respiratory infections 843 15.6%

74%

Diarrheal diseases 633 11.7%

HIV/AIDS 557 10.3%

Maternal conditions 278 5.2%

Malaria 277 5.1%

Neonatal infections and other conditions 252 4.7%

Birth asphyxia and birth trauma 237 4.4%

Tuberculosis 187 3.5%

Other infectious diseases (meningitis, STDs excluding HIV, childhood-cluster diseases, upper respiratory infections, Hepatitis B, Hepatitis C)

180 3.3%

Tropical-cluster diseases 170 3.2%

Prematurity and low birth weight 155 2.9%

Protein-energy malnutrition 128 2.4%

Nutritional deficiencies 102 1.9%

Congenital anomalies

Unipolar depression

Asthma

EpilepsyDiabetes mellitus

COPD

Cervical cancerLymphomas

Rheumatic heart disease

Myocarditis


FIGURE 1.1 The Long Tail of Endemic NCDs in Rwanda

1.2 A Framework for Strategic Planning for Endemic Non-Communicable Disease

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8$%:'#8$9'A&&5'34+$"*4'#847'+$9'5)@4%#'-%4+)&"*':$9-&<4%'$95'6"95*'6%&:':&%4'-%4@$.49#'84$.#8'-%&3.4:*>

Referral centers (1 per 5–10

million people)

District hospitals (1 per 250,000

people)

Health centers(1 per 20,000

people)

Community health workers

(1 per 200 people)

Health facilities

Integratedchronic care

Integrated gynecology(benign and malignant)

PathologyCardiac surgery

Cancer center

Medical specialties

Surgical specialties Radiology

2nd-level acute care generalist physicians


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FIGURE 1.2 Units of Planning for the Long-Tail Endemic NCDs


1.3 Decentralization and Integration of Chronic Care for Non-Communicable Disease in Rwanda

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1.4 Which Chronic Diseases?

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1.5 The District Hospital as a Source of Clinical Leadership

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?9)#)$..7C'<4'#%$)945'$5@$9+45'9"%*4*'$#'5)*#%)+#'+.)9)+*'#8%&"A8'5$).7C'5)%4+#'-$#)49#':$9$A4:49#'<)#8'-87*)+)$9*>'L*'#84'-%&A%$:'A%4<C'<4'6&%:$.)^45'#8)*'-%&+4**')9#&'$'#8%442:&9#82.&9A'#%$)9)9A'+"%%)+".":')9'$5@$9+45'+8%&9)+'5)*4$*4':$9$A4:49#'$95'3$*)+'4+8&+$%5)&A%$-87>'H84'-%&A%$:')9+."54*'3&#8'5)5$+#)+'$95'-%$+#)+$.'#%$)9)9A'37'-87*)+)$9*'$95'-%4@)&"*.7'#%$)945'$5@$9+45'9"%*4*>

L#'#84'*$:4'#):4C'$9'466&%#'#&'54@4.&-'$'#%$)9)9A'*#%$#4A7'6&%'84$.#8'+49#4%k.4@4.'+.)9)+)$9*'%4O")%45'A%4$#4%'+&&%5)9$#)&9'&6'+8%&9)+'+$%4'*4%@)+4*>'?9'#8)*':&54.C'-%&A%$:'.4$54%*')9'`S(*C'94"%&-*7+8)$#%7C'$95')964+#)&"*'5)*4$*4*'V,?\'$95'H!X'6&%:'$'+8%&9)+'+$%4'#4$:'#8$#'#%$)9*'$95':49#&%*'$'A%&"-'&6'84$.#82+49#4%'+.)9)+)$9*')9'#84'3$*)+':$9$A4:49#'&6'#84*4'+&95)#)&9*'V*44'FIGURE 1.3X>'TABLE 1.3 -%&@)54*'$'*$:-.4'*+845".4'&6'#84'+.)9)+$.'$95'#%$)9)9A'5"#)4*'&6'5)*#%)+#2.4@4.'+.)9)+)$9*>

Specialist physicians (1–2 per

specialty)

Generalist physicians

(4–10)

NCD nurses

(2–3)

HIV and TB nurses

(4–5)

Neuro-psychiatric

nurses(2–3)

Integrated chronic care nurses (2–3)

Integrated chronic care CHWs (2)

Health Workers(Number per Facility)

Referral centers (1 per 5–10

million people)

District hospitals (1 per 250,000

people)

Health centers(1 per 20,000

people)

Community health workers

(1 per 200 people)

Health facilities

TABLE 1.3 Sample District Hospital–Based Clinician Schedule

Monday Tuesday Wednesday Thursday Friday

Nurse 1 Preceptorship of health center nurses

Teaching (didactics)

District hospital heart failure clinic and preceptorship


Administration

Nurse 2 District hospital hematology/ oncology and preceptorship

District hospital chronic respiratory disease and preceptorship


District hospital advanced diabetes and hypertension clinic and preceptorship



FIGURE 1.3 Integration of Human Resources for Chronic Care


1.6 District Inpatient Care

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1.7 Health Centers: Case Finding, Initial Management, and Chronic Care

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1.8 Referral Centers

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1.9 Out-of-Country Referral

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1.10 Screening

?9'*&:4'*4##)9A*C'+&::"9)#723$*45'*+%449)9A'6&%'+&::&9'+8%&9)+''

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1.11 Principles of Patient Follow-Up and Retention: Community Health Workers and the Electronic Medical Record

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1.12 Equipment, Medication Procurement, and Costs

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http://modules.openmrs.org/modules


Chapter 1!References

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Disease-specific therapy

Diagnosis Death

Palliative careBereavement

chapter 2Palliative Care and Chronic Care

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FIGURE 2.1 Diagram of Palliative Care throughout the Course of Illness and Bereavement (Adapted from WHO)1

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2.1 History and Philosophy of Palliative Care E"orts in Resource-Poor Settings

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2

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chapter!2 | palliative care and chronic care 19

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TABLE 2.1 Cost/Impact Matrix of Medical Interventions, with Examples

High impact of therapy Low, marginal impact of therapy

High cost multidrug-resistant TB

cardiomyopathy

medications

Low cost without high-risk features

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2.2 Community Health Workers and Common Palliative Care Interventions in the Treatment of Chronic Disease

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?9'#8)*':&54.C'$'+49#%$.'-$..)$#)@4'+$%4'"9)#'<)..'-%&@)54'&@4%*)A8#C')9+."52)9A'#%$)9)9AC':&9)#&%)9AC'$95'*"-4%@)*)&9>'?#'$.*&'<)..'49*"%4'3&#8'#8$#'&-)&)5'-$)9':45)+$#)&9')*'$++4**)3.4'37'$97&94')9'9445'$95'#8$#'#84'%)*P'&6'&-)&)5'5)@4%*)&9'6&%')..)+)#'-"%-&*4*')*':)9):)^45>'H8)*'"9)#':$7'34'.&+$#45'<)#8)9'"9)@4%*)#7'#4$+8)9A'8&*-)#$.*>'L#'5)*#%)+#'[email protected]'-$.2.)$#)@4'+$%4'<)..'34')9#4A%$#45')9#&'4E)*#)9A'6"9+#)&9*'&6'-87*)+)$9*'$95'$5@$9+45'`S('9"%*4*>'G87*)+)$9*'<)..'-4%6&%:')9)#)$.'4@$."$#)&9*'&6'-$2#)49#*')9'9445'&6'8&:423$*45'-$..)$#)@4'+$%4'$95'-%4*+%)34':45)+$#)&9*C')9+."5)9A'&%$.':&%-8)94>'`S('9"%*4*'<)..'#849'34'+8$%A45'<)#8':&9)#&%2)9A'#84*4'-$#)49#*'$95'<)#8'-%&@)5)9A'&@4%*)A8#'&6'84$.#8'+49#4%k3$*45'9"%*4*>'L#'#84'84$.#82+49#4%'[email protected]'9"%*4*'<)..'$5D"*#'-%4*+%)-#)&9*'$95'-%&@)54'&@4%*)A8#'$95'#%$)9)9A'#&'#84'+&::"9)#7'84$.#8'<&%P4%*>'L..'4**49#)$.'-$..)$#)@4'+$%4':45)+$#)&9*'*8&".5'34'$@$).$3.4'$#'#84'84$.#82+49#4%'.4@4.')9'&%54%'#&':$E):)^4'-$#)49#'$++4**>'L#'#84'+&::"9)#7'[email protected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

2.2.1 Assessment of SymptomsH%"4')9#4A%$#)&9'&6'-$..)$#)&9'<)#8)9'$':&54.'&6'+8%&9)+'5)*4$*4'+$%4')9+."54*'$'#8&%&"A8'$**4**:49#'&6'-87*)+$.'$95'-*7+8&*&+)$.'5)*#%4**'$#'#84'#):4'&6'5)*4$*4'5)$A9&*)*>'H84*4'4.4:49#*'*8&".5'34'%4@)4<45'&9'4$+8'%4#"%9'@)*)#'$*'-$%#'&6'#84'$**4**:49#'&6'5)*4$*4'+&9#%&.>'H84'9445*'&6'#84'6$:).7':4:34%*'84.-)9A'#&'+$%4'6&%'#84'-$#)49#'$.*&'*8&".5'34'$*2*4**45')9#4%:)##49#.7>'b6#49C'-$..)$#)@4'466&%#*'<)..')9+."54'54.)@4%)9A':$2#4%)$.'*"--&%#'#&'6$:).)4*'):-&@4%)*845'37'#84'-$#)49#=*')..94**C')9+."5)9A'84.-'<)#8'8&"*)9AC'6&&5C'$95'*+8&&.'644*>'L55%4**)9A'#84'*&+)$.'9445*'&6'#84*4'-$#)49#*'$95'#84)%'6$:).)4*'%4O")%4*'+&&%5)9$#)&9'<)#8'A&@4%9:49#':)9)*#%)4*'49A$A45')9'$A%)+".#"%4C'45"+$#)&9C'$95'*&+)$.'<4.6$%4>

G$..)$#)@4'+$%4'%4*4$%+84%*'8$@4'54@4.&-45'$'@$.)5$#45'O"4*#)&99$)%4C'<8)+8'8$*'3449'#4*#45')9'%"%$.'*"32Y$8$%$9'L6%)+$9'*4##)9A*'V*44'TABLE 2.2X>/B'H84*4'O"4*#)&9*'<)..'9&#'34'$--.)+$3.4'6&%'$..'-$#)49#*'<)#8'+8%&9)+'


)..94**C'*"+8'$*'#8&*4'<)#8':).5'$*#8:$'&%'87-4%#49*)&9>'_4'8$@4')9+&%-&%$#45'#84*4'O"4*#)&9*')9#&'&"%'+.)9)+$.'6&%:*'<84%4'$--%&-%)$#4')9'#84';<$95$9'`S('+.)9)+*>'_4'$%4')9'#84'-%&+4**'&6'54@4.&-)9A':&%4'

37'+&::"9)#7'84$.#8'<&%P4%*>

TABLE 2.2 Symptom Assessment Scale (Adapted from the African Palliative Outcomes Scale)13

Questions for patient:

Q1. Please rate your pain during the last 3 days 0 (no pain) – 5 (worst/overwhelming pain)

Q2a. Have any other symptoms (e.g., nausea, coughing, or constipation) been a#ecting how you feel in the last 3 days?

Q2b. If so, please rate each symptom during the last 3 days: Dyspnea? Nausea or vomiting? Constipation? Diarrhea? Others? (specify)

0 (no, not at all) – 5 (overwhelmingly)

0 (no, not at all) – 5 (overwhelmingly)0 (no, not at all) – 5 (overwhelmingly)0 (no, not at all) – 5 (overwhelmingly)0 (no, not at all) – 5 (overwhelmingly)0 (no, not at all) – 5 (overwhelmingly)

Q3. Have you been feeling worried about your illness in the past 3 days?

0 (no, not at all) – 5 (overwhelming worry)

Q4. Over the past 3 days, have you been able to share how you are feeling with your family or friends?

0 (no, not at all) – 5 (yes, I’ve talked freely)

Q5. Over the past 3 days, have you felt that life was worthwhile?

0 (no, not at all) – 5 (yes, all the time)

Q6. Over the past 3 days, have you felt at peace? 0 (no, not at all) – 5 (yes, all the time)

Q7. Over the past 3 days, have you had enough help and advice for your family to plan for the future?

0 (no, not at all) – 5 (as much as wanted)

Questions for family caregiver:

Q8. Over the past 3 days, how much information have you and your family been given?

0 (none) – 5 (as much as wanted)N/A

Q9. Over the past 3 days, how confident has the family felt caring for the patient?

0 (not at all) – 5 (very confident)N/A

Q10. Has the family been feeling worried about the patient over the last 3 days?

0 (not at all) – 5 (severe worry)N/A

2.2.2 Symptom Management

&%':&%4'+&::&9C'5)*#%4**)9A'*7:-#&:*>'H84%$-)4*'$):45'$#'#84*4'

#%4$#:49#'$.A&%)#8:*>',4%4'<4'#&"+8'&9'*&:4'&6'#84'-%)9+)-.4*'&"#.)945')9'#84'?9#4A%$#45'R$9$A4:49#'&6'L5".#'$95'L5&.4*+49#'?..94**'G$..)$2#)@4'S$%4'T")54.)94'R&5".4C'#84'\)4#9$:'R)9)*#%7'&6',4$.#8'T")54.)94*'&9'G$..)$#)@4'S$%4'6&%'S$9+4%'$95'L?(Y'G$#)49#*C'$95'#84',&*-)+4'L6%)+$'aA$95$'G$..)$#)@4'R45)+)94'T")54>JC0C/J'S84:&#84%$-7'$95'%$5)$#)&9'#84%$-7C'3&#8'&6'<8)+8'8$@4'):-&%#$9#'%&.4*')9'%4.)4@)9A'-$)9'$95'&#84%'


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2.2.3 PainG$)9'$++&:-$9)4*':$97'+8%&9)+'5)*4$*4*'$95')*'$':$D&%'+$"*4'&6'5)*2$3).)#7'$95'*"664%)9A>',&<4@4%C'$++4**'#&'-$)9'%4.)46'#7-)+$..7')*'.):)#45'&%'9&94E)*#49#')9'%4*&"%+42-&&%'*4##)9A*>'R$97'+&"9#%)4*'*4@4%4.7'%4*#%)+#'#84'"*4'&6':&%-8)94'&"#'&6'64$%'&6'&-)&)5'5)@4%*)&9'&%'#84'+%4$#)&9'&6'$55)+#)&9'$:&9A'-$#)49#*>'L'J11K'*#"57'37'#84'?9#4%9$#)&9$.'`$%+&#)+*'S&9#%&.'!&$%5'%4@4$.45'#8$#'+&"9#%)4*'<)#8'g1m'&6'#84'<&%.5=*'-&-"2.$#)&9'+&:-%)*45'&9.7'Zm'&6'#84'<&%.5=*'#&#$.'&-)&)5'+&9*":-#)&9>/K',&<4@4%'*4@4%$.'+&"9#%)4*')9'*"32Y$8$%$9'L6%)+$C')9+."5)9A'aA$95$C'Y&"#8'L6%)+$C'$95';<$95$'8$@4'$5&-#45'-&.)+)4*'#&')9+%4$*4'$++4**'#&'&-)$#4*>/0C/Z

H84%4'$%4'#<&':$D&%'+$#4A&%)4*'&6'+8%&9)+'-$)9C'<8)+8'&6#49'%4O")%4'5)6264%49#'#84%$-)4*>

2.2.3.1 Nociceptive Pain`&+)+4-#)@4'-$)9')*'+$"*45'37'#84'*#):".$#)&9'&6'-$)9'%4+4-#&%*'$#'#84'495'&6'9&%:$.'*49*&%7'94%@4*'#8$#':45)$#4'-$)9>'`&+)+4-#)@4'-$)9')*'6"%2#84%'*"35)@)545')9#&'*&:$#)+'$95'@)*+4%$.'-$)9>'Y&:$#)+'%4+4-#&%*')9'#84'*P)9C'*&6#'#)**"4*C':"*+.4C'&%'3&94'$%4'*#):".$#45C'$95'#84'%4*".#)9A'-$)9'"*"$..7')*'4$*7'6&%'#84'-$#)49#'#&'.&+$.)^4'$95'54*+%)34>'G$)9')9'#84'*P)9')*'&6#49'*8$%-C'3"%9)9AC'&%'#8%&33)9A>'G$)9')9'#84':"*+.4')*'&6#49'A9$<)9A'&%'5"..>'G$)9')9'#84'3&94')*'$.*&'A9$<)9A'$95'5"..C'3"#'+$9'34+&:4'*8$%-'<)#8':&@4:49#>'\)*+4%$.'-$)9'#7-)+$..7')*'9&#'.&+$.)^45C'3"#':&%4'5)66"*4C'$95':$7'34'%464%%45'#&'$'*)#4'5)*#$9#'6%&:'#84'.4*)&9>'?#':$7'34'5"..'&%'*8$%-'$95':$7'-%&5"+4'$'644.)9A'&6'-%4**"%4>'?#')*'+$"*45'37'*#):".$#)&9'&6'-$)9'%4+4-#&%*')9')9#4%9$.'&%A$9*C')9+."5)9A'8&..&<'@)*+4%$>'?#':$7'34'5"4'#&'3.&+P$A4C'*<4..)9AC'&%'*#%4#+8)9A'&6'#84'&%A$9*'5"4'#&':4#$*#$*4*C'

2.2.3.2 Neuropathic Pain`4"%&-$#8)+'-$)9')*'+$"*45'37'5$:$A4'#&'94%@4*'&%'3%$)9>'`4"%&-$#8)+'-$)9')*'&6#49'54*+%)345'$*'3"%9)9A'&%'.)P4'$9'4.4+#%)+'*8&+P>'H84%4'$.*&'+$9'34'9":394**C'#)9A.)9AC'&%'$..&579)$'V-$)9'%4*".#)9A'6%&:'$'*#):"."*'#8$#'9&%:$..7')*'9&#'-$)96".C'*"+8'$*'.)A8#'#&"+8X')9'#84'$%4$')994%@$#45'37'#84')9D"%45'94%@4*>'H8)*'#7-4'&6'-$)9')*'@4%7'+&::&9'$:&9A'&"%'5)$234#)+C'+$9+4%C'$95',?\iL?(Y'-$#)49#*>'L97'P)95'&6')9D"%7'#&'94%@4'#)**"4'

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2$#4'&%'*4@4%4'-$)9'&6'$97'P)95C')9+."5)9A'94"%&-$#8)+'-$)9>',&<4@4%C'94"%&-$#8)+'-$)9'*&:4#):4*')*'9&#'%4.)4@45'37'&-)&)5'&%'9&92&-)&)5'#%4$#:49#>'?9'#8)*'*)#"$#)&9C'$5D"@$9#':45)+$#)&9*C'*"+8'$*'$:)#%)-#72.)94'&%'-8497#&)9C'+$9'34'"*46".>'?9'&#84%'*)#"$#)&9*C'$5D"@$9#':45)+$2#)&9*'+$9'34'"*45'#&'%45"+4'&%'4.):)9$#4'#84'9445'6&%'&-)&)5'#84%$-7>'[&%'4E$:-.4C'4@49'*4@4%4'-$)9'+$"*45'37'.)@4%':4#$*#$*4*'*&:4#):4*'+$9'34'%4.)4@45'<)#8'$'*#4%&)5C'*"+8'$*'-%459)*&.&94'&%'54E$:4#8$*&94>

FIGURE 2.2 The WHO Three-Step Pain Ladder1

Severe pain or pain persisting/increasingStrong opioid+/- non-opioid+/- adjuvant

Moderate pain or pain persisting/increasingWeak opioid (or low-dose strong opioid)+/- non-opioid+/- adjuvant

Mild painNon-opioid (paracetamol or NSAID)+/- adjuvant


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2#)&9*')9'#84'8&:4>'?9';<$95$C'.)O")5':&%-8)94'-%4-$%$#)&9*'<)..'34'5)*#%)3"#45'37'+&::"9)#7'84$.#8'<&%P4%*'6&..&<)9A')9)#)$.'-%4*+%)-2#)&9'37'$'-87*)+)$9>'F)O")5':&%-8)94')*':$54'6%&:'-&<54%')9'@$%)&"*'+&9+49#%$#)&9*'54-495)9A'&9'#84'-$#)49#=*'9445*>'VY44'APPENDIX A'6&%'&%$.':&%-8)94'%4+)-4*>X'_849'-$#)49#*'+$9'9&'.&9A4%'#&.4%$#4'&%$.':45)+$#)&9*C'3"++$.'&%'%4+#$.'%&"#4*':$7'34'"*45>'!4+$"*4'#84'$32*&%-#)&9'&6':&%-8)94'37'#84*4'%&"#4*')*'"9-%45)+#$3.4C'8)A84%'5&*4*':$7'34'%4O")%45>

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34'$5D"*#45'$#'*"3*4O"49#'@)*)#*'3$*45'&9'#84'-$#)49#=*'-$##4%9'&6'3&<4.':&@4:49#*>'b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

*.44->';4*-)%$#&%7'54-%4**)&9')*'$'%$%4'*)54'4664+#'&6'&-)&)5'#84%$-7'<849'A")54.)94*'$%4'6&..&<45C'$95')#'94@4%'&++"%*'346&%4'*45$#)&9>'

TABLE 2.3'.)*#*'#84'4**49#)$.'-$)9':45)+$#)&9*'V3$*45'&9'#84';<$95$9'6&%:".$%7X'#8$#'*8&".5'34'$@$).$3.4'$#'#84'84$.#82+49#4%'.4@4.>


TABLE 2.3 Essential Medications for Pain Relief

Symptom Medication Dose Notes

Mild pain/ fever reducers(non-opiates)

Acetaminophen/ paracetamol

Adult: 0.5–1 gram every 4 to 6 hours. Not to exceed 4 grams in 1 dayChild: 10-15 mg/kg (maximum 90 mg/kg/day divided every 4–6 hours)

Use maximum 2 grams per day in patients with enlarged livers or known liver disease. Very toxic to liver in overdose.

Ibuprofen Adult: 400–800 mg every 6-8 hours (maximum dose 2.4 gm/day)Child: 40 mg/kg/day every 6–8 hours

Particularly e#ective in bone pain. Anti-inflammatory at higher doses. Can cause digestive upset and gastrointestinal bleeding. Do not use in renal failure. Decrease doses in patients with severe liver failure. Prolonged prescription requires cimetidine or omepra-zole for gastrointestinal prophylaxis.

Diclofenac Adult: 25–75 mg every 12 hours

Same as ibuprofen, but less expensive for long-term use, with simpler dosing.

Moderate to severe pain

Morphine, liquid preparation

Adult: 2.5–10 mg every 4 hours. May give double dose at bedtime.No maximum dose. Titrate to patient comfort.Child: 0.15 mg/kg–0.3 mg/kg every 4 hours. Titrate as with adults.

Dose increases may be limited by oversedation.Should decrease the dose or increase the dosing interval in case of any renal failure.Constipation is a common problem and all patients should be placed on a bowel regimen prophylactically (see TABLE 2.5).

Neuropathic pain (burning pains or shooting)

Amitriptyline Adult: 10–25 mg by mouth daily.Child: 0.5 mg/kg once a day orally at bedtime. Increase as needed by 0.2–0.4 mg/kg every 2–3 days to maximum of 5 mg/kg/day.

Dose should be titrated upward every week to e#ect. May take weeks to work. Maximum dose in adults is 100 mg per day. Side e#ects include initial drowsiness, postural hypoten-sion, dry mouth, mild tachycardia, constipa-tion. Life-threatening cardiac toxicity with overdose.

Phenytoin Adult: 100 mg twice per day ini-tially, increase up to 400 mg twice per day if neededChild: 2.5–5 mg/kg twice per day (maximum 200 mg twice per day)

Can use instead of, or in addition to, amitrip-tyline if neuropathic pain persists. Avoid if on anti-retrovirals due to drug interactions.

Muscle spasms Diazepam Adult: 2.5–10 mg by mouth 2 to 3 times per dayChild: 0.05 mg/kg–0.1 mg/kg 3 to 4 times per day

Drowsiness, ataxia.


Symptom Medication Dose Notes

Pain from swelling, inflammation, or neuropathy

Prednisolone Adult: 20–80 mg by mouth dailyChild: 1 mg/kg x 1–2x/day by mouth

May also improve nausea, fatigue, and appetite. Particularly helpful in the case of malignant lesions causing localized swelling in the muscle or bone. The dose should be decreased gradually over a period of 2–3 weeks and then stopped to avoid side e#ects.

2.2.4 Dyspnea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

2.2.5 Nausea/Vomiting`$"*4$'$95'@&:)#)9A'&++"%'<)#8':$97'+8%&9)+'5)*4$*4*C'4)#84%'$*'$'%4*".#'&6'#84'5)*4$*4'-%&+4**')#*4.6'&%'$*'$'*)54'4664+#'&6':45)+$#)&9*>'`$"*4$':$7'8$@4':$97'+$"*4*>'[&%')9*#$9+4C')9'84$%#C'.)@4%'$95'%49$.'6$)."%4C'#84'A"#'<$..*':$7'34+&:4'454:$#&"*'$95'6"9+#)&9'-&&%.7C'$'+&925)#)&9'#8$#'.4$5*'#&'9$"*4$'$95'@&:)#)9A>'`$"*4$2-%&5"+)9A'*"3*#$9+4*'#8$#'$%4'4)#84%'#$P49')9#&'#84'3&57'V*"+8'$*':45)+$#)&9*'&%'6&&5'#&E)9*X'&%'-%&5"+45'37'#84'3&57'V)9'.)@4%'&%'%49$.'6$)."%4C'6&%'4E$:-.4X'*#):".$#4'+4%#$)9'$%4$*'&6'#84'3%$)9'#8$#'+&9#%&.'9$"*4$'$95'@&:)#)9A>'TABLE 2.4')95)+$#4*'#84'$--%&-%)$#4'#84%$-7'6&%'9$"*4$'54-495)9A'&9'#84'+$"*4>'_849'-$#)49#*'+$99&#'#&.4%$#4'&%$.':45)+$#)&9C'#$3.4#*':$7'34'A%&"95'"-'$95':)E45'<)#8'<$#4%'6&%'%4+#$.')9*4%#)&9'@)$'$'*7%)9A4'<)#8&"#'$'9445.4>'

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TABLE 2.4 Essential Medications for Control of Nausea/Vomiting

Cause of nausea Therapy

Liver failure, renal failure, metabolic derangement, drug side e#ect, or bacterial infection (nausea due to a toxin or inflammatory mediator)

HaloperidolAdult: 0.5–1 mg 2–4 times per day given orally, IV, or SC, around the clock or as neededChild ( 40 kg): 0.025–0.05 mg/kg/day in 2–3 divided doses. Increase by 0.25–0.5 mg/day every 5–7 days as needed to maximum dose 0.15 mg/kg/day

PromethazineAdult: 12.5–25 mg every 4 hours orally, IV, IM, or by rectumChild ( 40 kg): 0.25–1 mg/kg 4 times a day orally, IV, IM, or by rectum. Maximum dose: 25 mg per dose

DexamethasoneAdult: 4–10 mg 2 times per day IV or IM, around the clock or as neededChild ( 40 kg): 0.5–1 mg/kg 2 times per day IV or SC around the clock or as needed. Maximum dose: 10 mg 2 times per day

Increased intracranial pressure, bowel obstruction, or distension of liver or of hollow viscus due to neoplasm

DexamethasoneAdult: 4–10 mg 2 times per day IV or IM, around the clock or as neededChild ( 40 kg): 0.5–1 mg/kg 2 times per day IV or SC around the clock or as needed. Maximum dose: 10 mg 2 times per day

Anxiety DiazepamAdult: 2.5–10 mg 3 times per day, orally, IV, or SC, around the clock or as neededChild ( 40 kg): 0.05–0.1 mg/kg/day divided 3–4 times per day

Gastroparesis Metoclopramide Adult: 10 mg, 4 times per day, orally, IV, or SC, around the clock or as needed.Child: 0.1-0.2 mg/kg/dose 4 times per day, orally, IV or SC, around the clock or as needed

Stimulation of vestibular apparatus

Chlorpheniramine Adult: 4 mg orally every 4 hours, around the clock or as neededChild ( 40 kg): 1–2 mg by mouth every 4–6 hours. Maximum dose: 6 mg/day for 2–5 yo, 12 mg/day for 6–11 yo, around the clock or as needed

PromethazineAdult: 12.5–25 mg every 4 hours orally, IV, IM, or by rectumChild: 0.25–1 mg/kg 4 times a day orally, IV, IM, or by rectum. Maximum dose: 25 mg

Adjuvants for nausea/ vomiting of any cause

ChlorpheniramineAdult: 4 mg orally every 4 hours, around the clock or as neededChild ( 40 kg): 1–2 mg by mouth every 4–6 hours. Maximum dose: 6 mg/day for 2–5 yo, 12 mg/day for 6–11 yo, around the clock or as needed

2.2.6 Constipation

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2$#45>'F$E$#)@4*'$95'494:$*':$7'$.*&'34'"*45'#&'4$*4'+&9*#)-$#)&9'V*44'TABLE 2.5X>'H84':&*#'+&::&9'#7-4*'&6'.$E$#)@4*'$%4'*#):".$9#*'V3)*$+&257.XC'&*:&#)+'$A49#*'V.$+#".&*4XC'$95'."3%)+$9#*'VA.7+4%)94X>'?9'-$#)49#*'<)#8'+&9*#)-$#)&9'5"4'-%):$%).7'#&'&-)&)5'#84%$-7C'$'*#):".$9#'.$E$#)@4')*'

$%4'<4..'875%$#45>'?9'*4@4%4'+$*4*'&6'&-)&)52)95"+45'+&9*#)-$#)&9C'&%$.'9$.&E&94'+$9'34'"*45'#&'%4@4%*4'#84'&-)&)5'4664+#'&9'#84'A"#>

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TABLE 2.6'&"#.)94*'#84'4@$."$#)&9'$95'#%4$#:49#'&6'5)$%%84$'9&#'&3@)&"*.7'5"4'#&')964+#)&9>'`$%+&#)+*'$95'$9#)+8&.)94%A)+':45)+$#)&9*'*"+8'$*'87&*+)94'3"#7.3%&:)54'+$9'84.-'%45"+4'5)$%%84$')6'.&-4%$:)54')*'9&#'$@$).$3.4>

TABLE 2.5 Essential Therapies for Treating Constipation

Treatment Dose

Glycerin suppository Adult: 4 gm suppository per rectum dailyChild ( 40 kg): 2 gm suppository per rectum daily

Lactulose syrup Adult: 15–45 ml 2–3 times per day orally, maintain 30–90 ml/dayChild ( 40 kg): 7.5 ml 1 time per day orally

Bisacodyl Adult: 10 mg once or twice daily, orally or per rectumChild ( 40 kg): 0.3 mg/kg once daily by mouth. Maximum dose: 10 mg. Can also be given per rectum

Naloxone Adult: 1–2 mg every 8 hours. Should only be given orally for this indication


TABLE 2.6 Symptomatic Management of Diarrhea

Treatment Dose

Loperamide Adult: 4 mg orally initially, then 2 mg orally after every loose stool, up to a maximum of 16 mg per dayChild (weight 13–20 kg): 1 mg orally 3 times per dayChild (weight 21–30 kg): 2 mg orally up to 3 times per day

Morphine, liquid preparation (low dose) Adult: 2.5 mg every 8 hours. May give orally, buccally, or rectallyChild ( 40kg): 0.15 mg/kg, up to 2.5 mg every 4 hours. Administer as with adults

Hyoscine butylbromide Adults: 10–20 mg every 6 hours orally or rectally

2.2.8 Delirium/AgitationG$#)49#*'<)#8'#4%:)9$.')..94**':$7'34+&:4'54.)%)&"*'<)#8'&%'<)#8&"#'

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TABLE 2.7 Management of Chronic Pruritus and Skin Care

Condition Treatment

Pruritus due to dry skin, renal failure

Emollient lotion such as calamine

Chlorpheniramine:Adult: 4 mg orally every 4 hours, around the clock or as neededChild ( 40 kg): 1–2 mg orally every 4 hours, around the clock or as needed

Contact dermatitis (e.g., from tape used in hospitals)

Remove allergenic substanceHigh-potency topical steroid such as 0.05% betamethasone valerate

Scabies Permethrin lotion applied from head (avoid face) to toes. Leave lotion on for 8–14 hours, then wash o#. The usual adult dose is 20–30 grams. Repeat in 1 week. Wash all clothes and bedding and dry in the sun. Do not use for babies less than 2 months old

Cholestasis Adult: Prednisolone 10 mg per day. Cimetidine 400 mg twice per day.

Pruritus due to opioids Chlorpheniramine: Adult: 4 mg orally every 4 hours, around the clock or as neededChild ( 40 kg): 1–2 mg orally every 4 hours, around the clock or as needed

Foul odor from wounds Keep wound clean. Crush metronidazole tables and sprinkle onto wound daily

2.2.10 Psychosocial and Spiritual Issues2

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chapter 3Role of Community Health Workers, Family Planning, Mental Health, and Social Services in the Treatment of Chronic Disease

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chapter!3 | community health workers and allied services 35

3.3 Nutritional Support

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3.4 Mental Health

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3.5 Family Planning in Chronic Disease

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chapter!3 | community health workers and allied services 37


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J' RULYa;U'(,Y'bR>';<$95$'(4:&A%$-8)+',4$.#8'Y"%@47'???>'J110W';<$95$'`?Y;h'J110>

chapter 4Heart Failure

,4$%#'6$)."%4'$++&"9#*'6&%'0m'#&'/1m'&6'8&*-)#$.)^$#)&9*'$:&9A'$5".#*'#8%&"A8&"#'*"32Y$8$%$9'L6%)+$>/2g'Y"%@47*'5$#)9A'3$+P'#&'#84'/d01*'*8&<'#8$#'#84*4'9":34%*'8$@4'9&#'+8$9A45'*"3*#$9#)$..7'6&%'$#'.4$*#'#84'-$*#'8$.62+49#"%7>'?9'#84'/dg1*'$95'/dd1*C'#84')9#%&5"+#)&9'&6'#<&25):49*)&9$.'4+8&+$%5)&A%$-87'84.-45'+.$%)67'#84'+$"*4*'&6'84$%#'6$)."%4')9'#8)*'*4##)9A>d';4-&%#*'6%&:'%464%%$.'+49#4%*'&9'#84'+&9#)949#'*8&<45'#8$#':&*#'+$*4*'&6'84$%#'6$)."%4'<4%4'5"4'#&'9&92)*+84:)+'+$%5)&:7&-$2#8)4*C'+&9A49)#$.'84$%#'5)*4$*4C'%84":$#)+'84$%#'5)*4$*4C'&%'87-4%#49*)@4'84$%#'5)*4$*4'%$#84%'#8$9'+&%&9$%7'$%#4%7'5)*4$*4'V*44'TABLE 4.1X>'U@49')9'"%3$9'+49#4%*'<)#8'$9')9+%4$*)9A'-%4@$.49+4'&6'@$*+".$%'%)*P'6$+#&%*C'9&92)*+84:)+'4#)&.&A)4*'&6'84$%#'6$)."%4'*#)..'5&:)9$#45>/12/g

† Age = Mean Age; * RHD = Rheumatic heart disease; ‡ DCM = Dilated cardiomyopathies; § EMF = Endomyocardial fibrosis; †† HTN HD = Hypertensive heart disease; ‡‡ ICM = Ischemic cardiomyopathy

tt These series reported total valvulopathies. §§ Patients were double counted if they had two etiologic processes.

TABLE 4.1 Causes of Heart Failure Reported by Selected Echocardiographic Referral Centers in Sub-Saharan Africa

Authors Country n Age† RHD. (%) DCM‡ (%) EMF§ (%) HTN HD†† (%) ICM‡‡ (%)

Amoah et al. 200019

Ghana 572 42 115 (20) 65 (11) 22 (4) 122 (21) 56 (10)

Freers et al. 19969

Uganda 406 N/A 58 (12) 40 (8) 99 (22) 38 (8) 4 (1)

Kingue et al. 200520

Cameroon 167 57 41 (25)tt 46 (27) 5 (12) 91 (55) 4 (3)

Thiam et al. 200221

Senegal 170§§ 50 76 (45)tt 12 (7) 0 (0) 58 (34) 30 (18)

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Rheumatic heart disease33%

8%

13%

3%

2%

41%Cardiomyopathy

Rheumatic heart diseaseOtherCor pulmonale

CardiomyopathyHypertensive heart diseaseCongenital heart disease


FIGURE 4.1 Distribution of Causes of Heart Failure in a Rwandan NCD clinic (n = 134)

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chapter!4 | heart failure 41

4.1 Defining Categories of Heart Failure

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TABLE 4.2 Important Diagnostic Categories in Heart Failure

1. Cardiomyopathy

Diagnostic criteria 1. Moderately to severely depressed left ventricular function (ejection fraction u 40%)

2. Hypertensive heart disease

Diagnostic criteria 1. Severe hypertension 2. Shortness of breath3. Normal to mildly depressed left ventricular function (ejection fraction 40%)

3. Mitral stenosis

Diagnostic criteria 1. Mitral valve that doesn’t open well with typical hockey-stick or elbow deformity2. Normal to mildly depressed left ventricular function (ejection fraction 40%)

4. Other valvular heart disease (including rheumatic and congenital)

Diagnostic criteria 1. Normal to mildly depressed left ventricular function (ejection fraction 40%)2. No mitral stenosis3. Blood pressure 180/110 mmHg4. Dramatic heart murmur

5. Isolated right heart failure

Diagnostic criteria 1. Ejection fraction 40% 2. No mitral stenosis3. Blood pressure 180/110 mmHg4. No heart murmur5. Large right ventricle or dilated inferior vena cava on echocardiography

4.2 Physical Exam Findings for Classification of Heart Failure

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Left ventricle

Right ventricle

Aorticroot

Left atrium

Mitral valve(anterior leaflet)

Mitral valve(posterior leaflet)


TABLE 4.3 Physical Exam Findings in Classification of Heart Failure

1. Dramatic murmurs2. Blood pressure 180 mmHg systolic or 110 mmHg diastolic

4.3 Echocardiography for Classification of Heart Failure

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TABLE 4.4 Echocardiographic Findings in Classification of Heart Failure

1. Moderately to severely decreased EF (u 40%)2. Mitral stenosis3. Very large right ventricle (much larger than the aortic root or left atrium)4. Clearly enlarged and non-collapsing vena cava ( 2.5 cm)

4.3.1 The Parasternal Long Axis ViewH84'-$%$*#4%9$.'.&9A'$E)*'@)4<')*'&3#$)945')9'#84'6&..&<)9A':$994%W'<)#8'#84'-$#)49#'.7)9A'&9'#84'.46#'*)54C'#84'-%&34')*'-.$+45'#&'#84'.46#'&6'#84'*#4%9":C')9'#84'K#8'&%'0#8')9#4%+&*#$.'*-$+4C'<)#8'#84'-%&34':$%P4%'-&)9#45'#&<$%5'#84'%)A8#'*8&".54%>'H84':)#%$.'@$.@4'$95'$&%#)+'@$.@4'*8&".5'34'+.4$%.7'*449'V*44'FIGURE 4.2'$95'FIGURE 4.3X>

FIGURE 4.2 Parasternal Long Axis View

Right ventricle

Left ventriclein diastole

Left ventriclein systole

Aorticroot

Leftatrium

Mitral valve

Closed mitral valve

(anterior leaflet)Mitral valve

(posterior leaflet)


FIGURE 4.3 Normal Parasternal Long Axis View on Echocardiography (Diastole, top; Systole, bottom)

4.3.2 The Subcostal ViewH84'*"3+&*#$.'@)4<')*'&3#$)945'<)#8'#84'-%&34'-.$+45'"954%'#84'E)-8&)5'

#84'.)@4%'*449'$#'#84'#&-'&6'#84'*+%449'V*44'FIGURE 4.4X>'H84'?\S')*'*449'$*'$'3.$+P'#"34'49#4%)9A'#84'%)A8#'@49#%)+.4'V*44'FIGURE 4.5X>'?#'*8&".5'34':4$*"%45'J'+:'6%&:')#*'49#%$9+4')9#&'#84'%)A8#'@49#%)+.4>'

Tricuspidvalve

Rightventricle

LeftventricleInferior vena cava (IVC)

Liver

Left atrium

Right atrium

Mitral valve


FIGURE 4.4 Subcostal View

Rightventricle

Leftventricle

TricuspidvalveRight atrium

Left atrium

Dilatedinferior

vena cava(IVC)

Liver

Liver

Right atrium

Inferiorvena cava

(IVC)

Mitral valve


FIGURE 4.5 Subcostal View with Normal IVC (top) and Dilated IVC (bottom)

_4'8$@4'6&"95'#8$#'$*'+.)9)+)$9*'34+&:4':&%4'$54-#'$#'#84*4'@)4<*C':$97'#$P4')#'"-&9'#84:*4.@4*'#&'.4$%9'#84'&#84%'3$*)+'4+8&+$%5)&A%$-82

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4.3.3 Ejection Fraction and Fractional Shortening2

#$9#'5)$A9&*#)+'*P)..')9'+$#4A&%)^)9A'84$%#'6$)."%4>'U['%464%*'#&'#84'$:&"9#'&6'3.&&5'#8$#'#84'84$%#'-":-*'&"#'<)#8'4$+8'34$#>'UD4+#)&9'6%$+#)&9')*'$':4$*"%4'&6'#84'84$%#=*'*7*#&.)+'6"9+#)&9W'8&<'<4..'#84'84$%#'<&%P*'5"%)9A'#84'*O"44^)9A'-8$*4'&6'#84'+$%5)$+'+7+.4>'L'9&%:$.'U[')*'34#<449'00m'$95'Z0mC':4$9)9A'#8$#'#84'9&%:$.'84$%#'-":-*'$3&"#'8$.6'&6'#84'3.&&5')9'#84'.46#'@49#%)+.4'&"#')9#&'#84'$&%#$'<)#8'4$+8'34$#>

00mXC'$95':&54%$#4.7'#&'*4@4%4.7'%45"+45'Vu'K1mX>'L':&54%$#4.7'#&'*4@4%4.7'%45"+45'U[':4$9*'$'-$#)49#'8$*'$'+$%5)&:7&-$#87C'$'6$)."%4'&6'#84'84$%#':"*+.4>'_8).4'4+8&+$%5)&A%$-87':$+8)94*'+$9'A494%$#4':4$*"%4:49#*'&6'U[C'O"$.)#$#)@4'@)*"$.'$**4**:49#')*':&%4'%4.)$3.4>'?9'$'+%&**2*4+#)&9$.'@)4<C'#8)*'#%$9*.$#4*')9#&'8&<':"+8'#84'<$..*'&6'#84'@49#%)+.4'$%4'*449'#&':&@4'#&<$%5'4$+8'&#84%'<)#8'4$+8'84$%#34$#>'H8)*'5)*#$9+4')*'+$..45'#84'6%$+#)&9$.'*8&%#49)9A>'L'9&%:$.'4D4+#)&9'6%$+#)&9'&6'00m'+&%%4*-&95*'#&'$'6%$+#)&9$.'*8&%#49)9A'&6'$3&"#'J0m>'H8)*':4$9*'#8$#'<849'#84'9&%:$.'84$%#'*O"44^4*')9'*7*#&.4C'#84'5)*#$9+4'34#<449'#84'<$..*'9$%%&<*'37'&9.7'J0m>

_4'#4$+8'&"%'+.)9)+)$9*'#&'4@$."$#4'U[')9'#84'-$%$*#4%9$.'.&9A'@)4<>'?#'+$9'$.*&'34'$**4**45')9'#84'-$%$*#4%9$.'*8&%#'$E)*C'$95'$-)+$.'K2+8$:34%'@)4<*>

FIGURE 4.3'*8&<*'#84'9&%:$.'%4.$#)&9*8)-'34#<449'#84'84$%#')9'5)$*#&.4'V%4.$E$#)&9X'$95'*7*#&.4'V+&9#%$+#)&9X>'`&#)+4'#8$#'#84'@&.":4'&6'#84'.46#'@49#%)+.4'54+%4$*4*')9'*7*#&.4C'$95'#84'.46#'@49#%)+".$%'<$..*'34+&:4'#8)+P4%'$*'#84'@49#%)+.4'+&9#%$+#*'$95'*O"44^4*'#84'3.&&5'&"#')9#&'#84'$&%#$>

FIGURE 4.6'*8&<*'8&<'#84'.46#'@49#%)+".$%'<$..*'5&'9&#':&@4'#&A4#84%'@4%7':"+8')9'$'84$%#'<)#8'$'+$%5)&:7&-$#87o#84'.46#'@49#%)+.4'%4:$)9*'$3&"#'#84'*$:4'*)^4'+&9#%$+#45'$*'%4.$E45C'$95'#84'<$..*'5&'9&#'#8)+P49':"+8>'S&:-$%4'#8)*'#&'#84'9&%:$.'84$%#')9'FIGURE 4.3>

Right ventricle

Leftatrium

Left ventriclein diastole

Left ventriclein systole

Aorticroot

Mitral valve

Closed mitral valve

(posterior leaflet)

Mitral valve(anterior leaflet)


FIGURE 4.6 Cardiomyopathy in Parasternal Long Axis View (Diastole, top; Systole, bottom)

4.3.4 Assessment for Mitral Stenosis?9'-$#)49#*'<)#8'%84":$#)+':)#%$.'*#49&*)*C'#84':)#%$.'@$.@4'8$*'$'*#%)P2)9A.7'+8$%$+#4%)*#)+'$--4$%$9+4')9'#84'-$%$*#4%9$.'.&9A'$E)*'@)4<'V*44'FIGURE 4.7X>'H84'64$#"%4*'&6'#7-)+$.'%84":$#)+':)#%$.'*#49&*)*')9+."54W'V/X'$'*:$..'&-49)9A'&6'#84':)#%$.'@$.@4')9'5)$*#&.4'V*44'FIGURE 4.3'$95'FIGURE 4.68$*'$'8&+P47'*#)+P'&%'4.3&<'546&%:)#7h'VBX'.46#'@49#%)+".$%'6"9+#)&9')*'#7-)+$..7'9&%:$.>'

Right ventricle

Leftatrium

Left ventriclein diastole Aortic

root

Mitral valve(anterior leaflet

with hockey stick or elbow deformity)Small opening

of stenotic mitral valve in diastole

Right ventricle(very dilated in diastole)


FIGURE 4.7 Mitral Stenosis in Diastole

4.3.5 Assessment of Right Heart Size?9'+$*4*'&6'%)A8#'84$%#'6$)."%4C'#84'%)A8#'@49#%)+.4':$7'$--4$%'49.$%A45'&9'#84'-$%$*#4%9$.'.&9A'$E)*'@)4<'V*44'FIGURE 4.8X>'`&%:$..7C'#84'%)A8#'@49#%)+.4')*'%&"A8.7'#84'*$:4'*)^4'$*'#84'$&%#)+'%&&#'$95'#84'.46#'$#%)":>'

FIGURE 4.8 Right Ventricular Enlargement (Parasternal Long View)


4.3.6 Assessment of the Inferior Vena CavaH84')964%)&%'@49$'+$@$')9'#84'*"3+&*#$.'@)4<'*8&".5'34'*:$..'$95'+&.2.$-*4'6"..7'<)#8'4$+8')9*-)%$#)&9>'L9'?\S'A%4$#4%'#8$9'J'+:'#8$#'5&4*9=#'+&..$-*4')*'*#%&9A.7'*"AA4*#)@4'&6'*&:4'4.4:49#'&6'%)A8#2*)545'84$%#'6$)."%4'V*44'FIGURE 4.5X>'

4.3.7 Assessment of Pericardial E!usion G4%)+$%5)$.'466"*)&9*'+$9'&++"%')9':$97'5)664%49#'#7-4*'&6'84$%#'6$)."%4>'H847'+$9'$.*&'&++"%')9'-$#)49#*'<)#8'9&'8)*#&%7'&6'84$%#'6$)."%4C'*"+8'$*'#8&*4'<)#8'+$9+4%'&%'%49$.'6$)."%4>'H847'$%4'.)*#45'84%4'$*'$'P47'4+8&+$%2

2

*8&".5'-%&:-#')::45)$#4'$5:)**)&9'#&'#84'5)*#%)+#'8&*-)#$.'6&%'-&**)3.4'

5)$A9&*#)+'+%)#4%)$'6&%'84$%#'6$)."%4'+$#4A&%)^$#)&9>'

*"3+&*#$.'@)4<C'3"#'+$9'$.*&'34'*449')9'#84'-$%$*#4%9$.'.&9A'$E)*'@)4<'V*44'FIGURE 4.9X>'R$97'-$#)49#*':$7'8$@4'*:$..'-4%)+$%5)$.'466"*)&9*>

Large pericardiale!usion

Large pericardiale!usion

Left ventricle

Left atrium

Liver


FIGURE 4.9 Pericardial E"usion (Parasternal View, top; Subcostal View, bottom)

4.4 Initial Recognition and Referral of the Heart Failure Patient

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L#'84$.#82+49#4%'[email protected]'84$%#'6$)."%4'-$#)49#*'&6#49'-%4*49#'<)#8'9&92

+.)9)+$..7'):-&%#$9#'84$%#'6$)."%4')9';<$95$'<)..'8$@4'*8&%#94**'&6'3%4$#8'$#'$'54+%4$*45'.4@4.'&6'$+#)@)#7>'S.)9)+)$9*'*8&".5'%464%'-$#)49#*''#&'#84'`S('+.)9)+'<8&'5&'9&#'8$@4'$9')964+#)&"*'-%&+4**'#&'4E-.$)9'#84)%'


TABLE 4.5'V*44'34.&<X'#&'*"AA4*#'$9'"954%.7)9A'+$%5)$+'4#)&.&A7>'CHAPTER 102&"#.)94*'#84'$+"#4'+$%4'84$.#8'+49#4%'$--%&$+8'#&'*8&%#94**'&6'3%4$#8>

TABLE 4.5 Common Signs and Symptoms of Heart Failure (Usually Present in Addition to Shortness of Breath)

1. Lower-extremity edema2. Loud murmurs3. Orthopnea (shortness of breath when lying prone)

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b9+4'+$%5)&:7&-$#87'8$*'3449'%".45'&"#C'-$#)49#*'$%4'$**4**45'6&%'#84'-%4*49+4'&6':)#%$.'*#49&*)*'&9'4+8&+$%5)&A%$-87>'H84*4'-$#)49#*'$%4'#%4$#45'$*'8$@)9A':)#%$.'*#49&*)*C'%4A$%5.4**'&6'#84'-%4*49+4'&6'&#84%'@$.@".$%'.4*)&9*'V*44'SECTION 4.10X>

G$#)49#*'<)#8&"#'+$%5)&:7&-$#87'&%':)#%$.'*#49&*)*'$%4'#849'$**4**45'6&%'-%4*49+4'&6'*4@4%4'87-4%#49*)&9>'?6'-%4*49#C'#847'$%4'+$#4A&%)^45'$*'8$@)9A'87-4%#49*)@4'84$%#'5)*4$*4'V*44'SECTION 4.9X>

;4:$)9)9A'-$#)49#*'$%4'#849'$**4**45'6&%'-%4*49+4'&6'$'84$%#':"%:"%>'H8&*4'<)#8'.&"5C'&3@)&"*':"%:"%*'<)#8&"#'+$%5)&:7&-$#87C':)#%$.'*#49&*)*C'&%'87-4%#49*)@4'84$%#'5)*4$*4'$%4'+$#4A&%)^45'$*'8$@)9A'*&:4'@$%)4#7'&6'+&9A49)#$.'&%'%84":$#)+'@$.@".$%'5)*4$*4'$-$%#'6%&:':)#%$.'*#49&*)*'V*44'SECTION 4.11X>

H84'%4:$)9)9A'-$#)49#*'$%4'4@$."$#45'6&%'*)A9*'&6')*&.$#45'%)A8#'84$%#'6$)."%4C'*"+8'$*'$'@4%7'.$%A4'%)A8#'@49#%)+.4'&%'$'5).$#45'?\S'&9'4+8&+$%2

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9&92+$%5)$+'+$"*4*'&6'#84)%'*7:-#&:*C'*"+8'$*'%49$.'&%'.)@4%'6$)."%4>

YES

NO

NO

NOYES

YES

YES

YES

NO

NO

NO

NO

YES YES

NO

YES

NO

YES

Consider alternate diagnoses

Suspected or confirmed heart failure

Signs ofdecompensated

heart failure?(Table 4.7)

Echo-confirmedheart disease?(Section 4.3)

Ultrasound available?

Abnormal left ventricular

function?

Murmur

BP ≥ 180/110 mmHg

Treat as valvular/ congenital disease

(Protocol 4.12)

Mitral stenosis?

Treat as mitralstenosis

(Protocol 4.11)

Treat ascardiomyopathy(Protocol 4.4)

Follow appropriate treatment protocol

according todiagnosis

(Protocols 4.3–4.18)

Treat as decompensated

heart failure (Protocol 4.2)

Treat as hypertensiveheart disease

(Protocol 4.8) Signsof right-

sided heartfailure

Large, non-collapsing

IVC or very large right ventricle

Treat as right-sided heart failure

(Protocol 4.15)


PROTOCOL 4.1 Initial Diagnosis and Management of Heart Failure

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4.5 Heart Failure Severity Classification

G$#)49#*'<)#8'84$%#'6$)."%4'&6'$97'4#)&.&A7'6$..'$.&9A'$'+&::&9'+&9#)9"2":'&6'*7:-#&:'*4@4%)#7>'H84*4'$%4'+$#4A&%)^45')9#&'6&"%'A%&"-*C'3$*45'

TABLE 4.6X>'

+.4$%.7'5&+":49#'$'84$%#'6$)."%4'-$#)49#=*'+.)9)+$.'+&"%*4>

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

TABLE 4.6 New York Heart Association Heart Failure Classification

Class I Patients with cardiac disease but no resulting limitation of physical activity. Ordinary physical activity does not cause symptoms.

Class II Patients with cardiac disease resulting in mild limitation of physical activity. Patients are comfortable at rest. Ordinary physical activity (farming, running, carrying water, climbing a hill) causes symptoms.

Class III Patients with cardiac disease resulting in moderate limitation of physical activity. Patients are comfortable at rest. Less than ordinary physical activity (light housework, walking on flat ground) causes symptoms.

Class IV Patients with cardiac disease resulting in severe limitation of physical activity. Patients have symptoms at rest. Any physical activity causes symptoms.

4.6 Decompensated Heart Failure

_849'$'-$#)49#=*'3&57')*'9&'.&9A4%'+&:-49*$#)9A'<4..'6&%'#84'54A%44'&6'84$%#'57*6"9+#)&9C'@&.":4'*#$#"*'$95'6"9+#)&9$.'$3).)#7'<)..'<&%*49>'H8)*')*'#4%:45'54+&:-49*$#45'84$%#'6$)."%4>'S."4*'#8$#'$'-$#)49#'8$*'49#4%45'#8)*'*#$#4'$%4'$39&%:$.'@)#$.'*)A9*'V*"+8'$*'.&<'3.&&5'-%4**"%4'$95'6$*#'84$%#'%$#4X'$95'*4@4%4'*7:-#&:*'&6'57*-94$'$95'&%#8&-94$'V*44'TABLE 4.7X>'H84*4'-$#)49#*'$%4'#&&'*)+P'#&'34'#%4$#45')9'#84'+&::"9)#7'$95'

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TABLE 4.7 Signs of Decompensated Heart Failure in Adults

Vital signs Blood pressure Very low (SBP 80 mmHg)Very high (SBP 180 mmHg)

Pulse Very low ( 40 bpm)Very high ( 120 bpm)

High respiratory rate 24 breaths/minute

Low oxygen saturation Saturation 90%

Symptoms Inability to lie down flatSevere dyspnea at rest

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TABLE 4.8'.)*#*'*&:4'&6'#84'+&::&9'%4$*&9*'6&%'$+"#4'<&%*49)9A'&6'$'

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454:$>',4$%#'6$)."%4'-$#)49#*'<)#8'*)A9*'&6'54+&:-49*$#)&9'$95'@4%7'8)A8'3.&&5'-%4**"%4*'*8&".5'%4+4)@4')::45)$#4')9#4%@49#)&9*'#&'.&<4%'3.&&5'-%4**"%4'V*44'SECTION 8.4'$95'TABLE 8.4X>

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TABLE 4.8 Reasons for Acute Decompensation in Patients with Heart Failure

1. Medication nonadherence or recent changes in medications

2. Change in diet (e.g., increase in salt intake)

3. Acute illness (e.g., pneumonia, rheumatic fever, endocarditis)

5. Worsening valvular disease

6. PregnancyExacerbates all types of heart failure, but especially mitral stenosis (2nd and 3rd trimester) and peripartum cardiomyopathy.

7. ArrhythmiaEspecially common in patients with cardiomyopathies and valvular disease, particularly mitral stenosis.

8. Worsened hypertensionVery high blood pressure can cause acute sti#ening of the heart muscle and back up of fluid into the lungs (pulmonary edema).

NO

NO

NO

YES

NO

YES

NO

YES

NO

YES

YES

Check creatinine,consider

alternative diagnosis

Initial furosemide dose (Table 4.10)

Diuresis within 30 minutes?

Dose escalation

(Table 4.10)

Diuresis after 1–2 dose

escalations?

Look for other reasons for

decompensation and treat accordingly

Lower blood pressure

(see Table 8.4, Section 8.4)

Signs of Decompensated Heart Failure(Table 4.7)

Place IV, hospitalize or prepare for transfer to

hospital

Signs of fluid overload

(Table 4.9)

Treat according to diagnosis

(Sections 4.8–4.12)

BP ≥ 180/110 mmHg?

HR ≥ 120 Obtain ECG

Signs of atrial fibrillation (irregularly spaced QRS and/or

no P waves)

Load withdigoxin, start

anticoagulation(see Section 4.16.1)


PROTOCOL 4.2 Management of Decompensated Heart Failure

4.7 Fluid Status Assessment

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2

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TABLE 4.9 Volume Status Categories and Diuretic Adjustment

Category Hypovolemic Euvolemic Hypervolemic

Mild Moderate Severe (decompensated)

Weight Less than dry weight

At dry weight 5 kg above dry weight

5 kg above dry weight

5 kg above dry weight

Symptoms Variable Class I–II Class I–II Class II–III Class III–IV

Vital signs TachycardiaHypotension

Normal Normal Mild tachycardia Tachycardia, tachypnea, hypoxia, hypotension, or hypertension

Physical exam

Does not always correlate with severity. Signs of fluid overload include distended neck veins, lung crackles, louder murmurs, hepatomegaly, ascites, and lower-extremity edema. However, can be intravascularly hypovolemic and still have signs of hypervolemia in lungs, extremities, and abdomen.

Creatinine Increased Stable or decreased

Stable or decreased

Can be increased (due to hypoperfusion of the kidneys), stable or decreased.

Diuretic adjustment

Stop all diuretics

Reduce or maintain dose (if starting beta-blocker, do not reduce diuretic)

Maintain or increase dose

Increase dose or add second agent

Start IV furosemide and prepare for transfer to hospital if possible

Hypovolemia

Decrease ORmaintain

diuretic dose

Stop alldiuretics,consider

giving fluids

Perform volume assessment

Mild

Hypervolemia

Moderate Severe

Low EFAND

starting orincreasing

beta-blockerdose

Maintain OR

increase diuretic

dose

Increase diuretic

dose

IV diuresis,hospitalize

Euvolemia

Maintaindiuretic

dose

Suspected or confirmed heart failure

NOYES


V*44'TABLE 4.9%)A8#2*)545'6$)."%4C'&%'%49$.'6$)."%4':$7'+&9#)9"4'#&'8$@4'%4*)5"$.'454:$'54*-)#4')9#%$@$*+".$%'4"@&.4:)$>'L*'$'-$#)49#'A4#*'+.&*4'#&'8)*'5%7'<4)A8#C'#84'+%4$#)9)94':$7'*#$%#'#&'%)*4>'H8)*')*'&94'*)A9'#8$#')#':$7'34'#):4'#&'54+%4$*4'$'-$#)49#=*'5)"%4#)+'5&*4>

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PROTOCOL 4.3'-%4*49#*'$9'$.A&%)#8:'6&%'$--%&-%)$#4':$9$A4:49#'&6'

PROTOCOL 4.3 Volume Status Assessment and Diuretic Adjustment


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5&*4'+$9'34'5&"3.45>'TABLE 4.10'-%&@)54*'*"AA4*#45'*#$%#)9AC'4*+$.$#)&9C'$95':$E):":'5&*4*'&6')9#%$@49&"*'6"%&*4:)54>'["%&*4:)54'.$*#*'$3&"#'Z'8&"%*'$95'*8&".5'34'5&*45'JkB'#):4*'-4%'5$7>

TABLE 4.10 Intravenous Furosemide (Lasix) Dosing

Initial dosing Escalation Maximum dose

Patient does not already take furosemide

Adult:40 mg IV 2x–3x/day

Double every 30 minutes until response or maximum dose achieved

Adult:100 mg IV 2–3x/day

Pediatric ( 40 kg):0.5 mg/kg IV 2x/day

Pediatric:2 mg/kg 2–3x/day

Patient already takes furosemide

Double e#ective outpatient dose and give as IV


["%&*4:)54')*'#<)+4'$*'4664+#)@4'<849'A)@49')9#%$@49&"*.7'$*'<849'A)@49'&%$..7>'?#')*'):-&%#$9#'#&'P44-'#8)*')9':)95'<849'#%$9*)#)&9)9A'-$#)49#*'6%&:'&94'6&%:'&6'#84'5%"A'#&'$9&#84%'V*44'TABLE 4.11X>

TABLE 4.11 Equivalent Oral and IV Furosemide (Lasix) Doses

Oral IV

80 mg PO 40 mg IV

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4.7.2 Guidelines for Initiating and Titrating Oral Furosemide at Health-Center Level

R&*#'-$#)49#*'<)#8'84$%#'6$)."%4'<)..'8$@4'$'#49549+7'#&'*#&%4'#&&':"+8'

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3$.$9+4'$95'#&'+&9#%&.'*7:-#&:*>'TABLE 4.12'&"#.)94*'#84'%4+&::49545'5&*)9A'&6'&%$.'6"%&*4:)54>

TABLE 4.12 Oral Furosemide (Lasix) Dosing

Initial dose Dose adjustment Maximum dose

Hypovolemia Euvolemia Mild hypervolemia

Moderate hypervolemia

Severe hypervolemia

Adult: 40 mg 1x/day

Stop all diuretics, consider giving fluid

May attempt to decrease dose unless starting or increasing beta-blocker

Keep dose the same

Double current dose or add second agent

Admission and intravenous diuresis (see TABLE 4.10)

Adult: 80 mg 2x/day

Pediatric:1 mg/kg 1x/day

Pediatric: 2 mg/kg 2–3x/day

4.7.3 Guidelines for Use of Other Diureticsb#84%'&%$.'5)"%4#)+*'34*)54*'6"%&*4:)54':$7'34'"*45'#&'84.-'$+8)4@4'$95':$)9#$)9'4"@&.4:)$'V*44'TABLE 4.13X>'H84*4':45)+$#)&9*'$%4'A494%$..7'$5545'#&'6"%&*4:)54'#&')9+%4$*4'#84'*#%49A#8'&6'5)"%4*)*>'_8).4'#847':$7'34'@4%7'4664+#)@4C'#84*4':45)+$#)&9*'+$9'$.*&')9+%4$*4'#84'+8$9+4*'&6'4.4+#%&.7#4'$39&%:$.)#)4*'$95'&#84%'*)54'4664+#*'&6'6"%&*4:)54C'$95'*8&".5'34'"*45'<)#8'+$"#)&9>


4.7.3.1 SpironolactoneY-)%&9&.$+#&94'V#%$54'9$:4'L.5$+#&94XC'.)P4'6"%&*4:)54C'$+#*'&9'#84'P)5947*'#&')9+%4$*4'"%)9$#)&9>'_8).4'6"%&*4:)54'#495*'#&'+$"*4'87-&P$2.4:)$C'*-)%&9&.$+#&94'<)..':$)9#$)9'&%')9+%4$*4'3.&&5'-&#$**)":'.4@4.*>'Y-)%&9&.$+#&94'+$9'34'-$%#)+".$%.7'4664+#)@4')9'-$#)49#*'<)#8'$*+)#4*>'!4+$"*4'*-)%&9&.$+#&94'+$9')9+%4$*4'3.&&5'-&#$**)":'.4@4.*C')#'*8&".5'&9.7'34'"*45')9'#84'*4##)9A'&6'9&%:$.'%49$.'6"9+#)&9>

4.7.3.2 Hydrochlorothiazide,75%&+8.&%&#8)$^)54')*'$'<4$P4%'5)"%4#)+'#8$9'6"%&*4:)54C'3"#'$+#*')9':"+8'#84'*$:4'<$7>'_849'#$P49'B1':)9"#4*'-%)&%'#&'6"%&*4:)54C'875%&+8.&%&#8)$^)54'+$9':$P4'6"%&*4:)54'<&%P'34##4%C'+$"*)9A'$'.$%A4%'5)"%4*)*>'L'@4%7'*:$..'9":34%'&6'-$#)49#*'*8&".5'%4O")%4'#8)*>'H8)*'+&:23)9$#)&9'+$9'+$"*4':$**)@4'5)"%4*)*'$95'.&**'&6'@)#$.'4.4+#%&.7#4*C'$95'#84%46&%4'*8&".5'&9.7'34'+&9*)54%45')9'+&9*".#$#)&9'<)#8'$'-87*)+)$9'$95'<)#8'@4%7'+.&*4':&9)#&%)9A'&6'4.4+#%&.7#4*>

TABLE 4.13 Other Oral Diuretic Dosing

Drug Initial dosing Notes Maximum dose

Spironolactone Adult: 25 mg 1x/day Add if patient has significant ascites and normal renal function

50 mg/day

Pediatric ( 40 kg): 2.5 mg/kg 1x/day

3 mg/kg/day

Hydrochlorothiazide Adult: 12.5 mg 1x/day Can be used if furosemide is not available or added to furosemide if greater diuresis is desired.

25 mg/day

Pediatric ( 40 kg): 1 mg/kg/day

12 mg/day

4.7.4 Dangers of Diuresis()"%4#)+*'$%4'-&<4%6".':45)+$#)&9*>'?6'"*45')9'4E+4**C'#847'+$9'+$"*4'4E+4**)@4'<$#4%'.&**'$95'%4*".#)9A'5$:$A4'#&'#84'P)5947*>'H8)*')9'#"%9'+$9'+$"*4'5$9A4%&"*'4.4+#%&.7#4'):3$.$9+4*'$95'4@49'54$#8>

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_849'$55)9A'#<&'5)"%4#)+*'#&A4#84%C'#84'4664+#'&9'4.4+#%&.7#4*')*')9+%4$*45>'S&:3)9$#)&9*'*8&".5'34'"*45'&9.7')9'#84'*4##)9A'&6'9&%:$.'+%4$#)9)94>'?6'-&**)3.4C'*&5)":C'-&#$**)":C'$95'+%4$#)9)94'*8&".5'34':&9)#&%45'$#'%4A".$%')9#4%@$.*')9'#84*4'*)#"$#)&9*>


4.8 Cardiomyopathy

H84'#4%:'+$%5)&:7&-$#87'49+&:-$**4*'*4@4%$.'#7-4*'&6'84$%#'5)*4$*4C'$..'&6'<8)+8'.4$5'#&'$'*):).$%'&"#+&:4'&6'84$%#':"*+.4'57*6"9+#)&9>'H84'+&::&9'64$#"%4'&6'$..'#84*4'5)*4$*4*')*'$'.&<'4D4+#)&9'6%$+#)&9C'"*"$..7'.4**'#8$9'K1m'V6%$+#)&9$.'*8&%#49)9A'.4**'#8$9'J1mX>'

H84%4'$%4':$97'5)664%49#'+$"*4*'&6'+$%5)&:7&-$#87'V*44'TABLE 4.14X>'L*'*#$#45'$3&@4C'*&:4'#7-4*'&6'84$%#'6$)."%4'34A)9'$*'$'+$%5)&:7&-$#87>'b#84%*C'8&<4@4%C'*"+8'$*'@$.@".$%'&%'87-4%#49*)@4'84$%#'5)*4$*4C'+$9'-%&A%4**'#&'$'+$%5)&:7&-$#87'&@4%'#):4>'L97'-$#)49#'<)#8'$9'4D4+#)&9'6%$+#)&9'.4**'#8$9'K1mC'%4A$%5.4**'&6'#84'+$"*4C'*8&".5'34'#%4$#45'-%)2:$%).7'$*'$'+$%5)&:7&-$#87>'S$%5)&:7&-$#8)4*'$664+#'-$#)49#*'&6'4@4%7'$A4'A%&"->

TABLE 4.14 Etiology of Cardiomyopathy in Rwanda

Idiopathic Most of the cases of cardiomyopathy are caused by an unknown process. Many may be due to a previous viral infection.

HIV cardiomyopathy HIV can cause direct cellular damage to heart muscle. ARVs can delay or reverse this process.

Alcohol-related cardiomyopathy

Chronic alcohol use can be toxic to the heart muscle. If the patient stops drinking alcohol, the function may improve with time.

Peripartum Women can develop a cardiomyopathy in the last month of pregnancy and up to six months postpartum. This often improves with appropriate management and avoidance of subsequent pregnancies.

Viral myocarditis Many di#erent viruses can infect the heart muscle and cause dysfunction. This often improves with time, but may be permanent.

Anemia Severe anemia (sometimes due to cancer or poor nutrition) can lead to cardiomyopathy. This can improve when the anemia is treated.

Advanced valvular disease

Most valvular conditions causing abnormal flow of blood within the heart can lead to a cardiomyopathy. This is particularly true with regurgitant lesions. This is not the case for pure mitral stenosis, in which the left ventricle is protected, while the right ventricle ultimately su#ers.

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

Assess fluid status, adjust furosemide(Protocol 4.3, Tables 4.9 and 4.12)

Adjust heart failure beta-blocker(Protocol 4.5)

Assess other medication needs(Protocol 4.7)

Follow-up planning(Section 4.13, Table 4.23)

Ejection fraction ≤ 40%

Assess vital signs, treatdecompensated heart failure

(Protocol 4.2)

Assess renal function and potassium, adjust ACE inhibitor OR hydralazine/isosorbide

(Protocol 4.6)


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PROTOCOL 4.4 Cardiomyopathy Management

4.8.1 Vital Sign AssessmentL*')9'$..'#7-4*'&6'84$%#'6$)."%4C'+$%5)&:7&-$#87':$9$A4:49#'34A)9*'<)#8'$9'$**4**:49#'&6'#84'-$#)49#=*'@)#$.'*)A9*'$95'&@4%$..'+&95)#)&9>'G$#)49#*'<)#8'+$%5)&:7&-$#8)4*'<)..'&6#49'8$@4'.&<'3.&&5'-%4**"%4*>',&<4@4%C'84$%#'6$)."%4'-$#)49#*'<)#8'*7*#&.)+'3.&&5'-%4**"%4*'34.&<'g1'::,AC'$.&9A'<)#8'&#84%'*)A9*'&6'54+&:-49*$#)&9'V#$+87+$%5)$C'%4*-)%$#&%7'5)*#%4**C'$.#4%45':49#$.'*#$#"*XC'*8&".5'34'8&*-)#$.)^45>


4.8.2 Fluid Status AssessmentH84'94E#'*#4-')9'#84':$9$A4:49#'&6'+$%5)&:7&-$#87')*'4@$."$#)&9'&6'

5)"%4#)+'5&*4*'*8&".5'9&#'34'%45"+45')6'34#$23.&+P4%*'$%4'A&)9A'#&'34'$5545'&%')9+%4$*45'$#'#84'*$:4'@)*)#>'H8)*')*'34+$"*4C')9'#84'*8&%#2#4%:C'

4.8.3 Titration of Mortality-Reducing Medications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

L#'#84'*4+&95'@)*)#C'#84'LSU')98)3)#&%':$7'34')9+%4$*45>'?9'#8)*':$994%C':45)+$#)&9*'$%4')9+%4$*45'&94'$#'$'#):4'"9#).'A&$.'5&*4*'$%4'$+8)4@45'&%'5&*42.):)#)9A'*)54'4664+#*'&++"%>


4.8.3.1 Beta-Blockers in Heart Failure!4#$23.&+P4%*'$%4'$'+.$**'&6'5%"A*'#8$#'<&%P'&9'%4+4-#&%*')9'#84'84$%#'#&'*.&<'84$%#'%$#4'$95'%45"+4'#84'<&%P'#84'84$%#':"*+.4':"*#'5&'<)#8'4$+8'*O"44^4>'?9'.$%A4'%$95&:)^45'#%)$.*C'+4%#$)9'#7-4*'&6'34#$23.&+P4%*'8$@4'3449'*8&<9'#&'%45"+4'#84'%)*P'&6'54$#8')9'-$#)49#*'<)#8'+$%5)&2:7&-$#8)4*'37'$%&"95'B1m>J]2B/'!4#$23.&+P4%*'*8&<9'#&'-%&.&9A'.)64')9'#84*4'84$%#'6$)."%4'-$#)49#*')9+."54'+$%@45).&.C':4#&-%&.&.'*"++)9$#4C'$95'3)*&-%&.&.>

L#49&.&.')*'#84'34#$23.&+P4%':&*#'&6#49'$@$).$3.4')9'.&<2%4*&"%+4'*4#2

J11g'_,b':&54.'5%"A'6&%:".$%7'V#8&"A8'$*'$'#%4$#:49#'6&%'$9A)9$C'9&#'6&%'84$%#'6$)."%4X>BJ'a96&%#"9$#4.7C'#84%4')*'9&'-%&*-4+#)@4C'%$95&:)^45'5$#$'#&'*"--&%#')#*'"*4')9'-$#)49#*'<)#8'+$%5)&:7&-$#8)4*>BB

?9'+&:-$%)9A'#84'-%)+4'&6'84$%#'6$)."%4'34#$23.&+P4%*'V$..'A494%)+'$#'#8)*'-&)9#XC'<4'8$@4'6&"95'#84'-%)+4'&6'+$%@45).&.'#&'34'#84'.&<4*#'#8%&"A8'&"%'"*"$.'5)*#%)3"#&%*'V*44 APPENDIX BX>'_4'8$@4'D"5A45'#8$#'#84'

2

TABLE 4.15 Mortality-Reducing Medications for Cardiomyopathy

Beta-blocker

Starting dose Dose change Target dose

Carvedilol 3.125–6.25 mg 2x/day 3.125–6.25 mg 2x/day 25 mg 2x/day

Atenolol* 12.5 mg 1x/day 12.5 mg 1x/day 50 mg 1x/day

ACE inhibitor


Lisinopril 5 mg 1x/day 5 mg 1x/day 20 mg 1x/day

Captopril 12.5 mg 3x/day 12.5 mg 3x/day 50 mg 3x/day

Enalapril 2.5 mg 2x/day 2.5 mg 2x/day 10–20 mg 2x/day

Hydralazine/isosorbide dinitrate(Contraindications to beta-blocker and/or ACE inhibitor)


Hydralazine 25 mg 3x/day 25 mg 3x/day 50 mg 3x/day

Isosorbide 10 mg 3x/day 10 mg 3x/day 30 mg 3x/day

Potassium-sparing diuretic


Spironolactone 12.5–25 mg 1x/day 12.5 mg 1x/day 25 mg 1x/day

* Only if no carvedilol or other heart failure beta-blocker available.


L#49&.&.'+$9'34'"*45')6'9&'84$%#'6$)."%4'34#$23.&+P4%')*'$@$).$3.4>

!4#$23.&+P4%*'*8&".5'34'"*45'<)#8'+$"#)&9')9'-$#)49#*'<)#8'+$%5)&:7&-2

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&6'34#$23.&+P4%*')9+."54'$AA%$@$#)&9'&6'$*#8:$'*7:-#&:*C'3%$57+$%5)$C'$95'87-&#49*)&9>

PROTOCOL 4.5'-%&@)54*'A")5$9+4'&9'34#$23.&+P4%'#)#%$#)&9')9'+$%5)&:72&-$#87>

NOYES

YES

YES

NO

NO

YES

NO

Increasebeta-blocker

dose(Table 4.15)

Cardiomyopathy, diuretic adjustments made

HR 50–60 bpm

HR ≤ 50 bpmOR

SBP ≤ 80 bpm

Decrease or do not startbeta-blocker

Fluid overload

(Table 4.9)

Maintain or do not start

beta-blocker

Maintain or do not start

beta-blocker

At target dose of beta-blocker (Table 4.15)

ORplan to increase

ACE inhibitorOR

decrease diuretic


4.8.3.2 ACE InhibitorsLSU')98)3)#&%*'$%4'$'+.$**'&6':45)+$#)&9'#8$#'<&%P'&9'#84'P)5947*C'3.&&5'

%4#49#)&9'$95'-%4@49#'8$%:6".'%4:&54.)9A'&6'84$%#':"*+.4>'H847'8$@4'3449'*8&<9'#&'%45"+4':&%#$.)#7'37'$%&"95'B1m')9'-$#)49#*'<)#8'+$%25)&:7&-$#8)4*>BK2B]'L.#8&"A8'$..'LSU')98)3)#&%*'$%4'$++4-#$3.4'6&%'"*4C'.)*)9&-%).'8$*'#84'.&<4*#'+&*#'$95'%4O")%4*'&9.7'&9+4'-4%'5$7'5&*)9A'V*44'TABLE 4.15'$95'APPENDIX BX>

?9'#84'-%4*49+4'&6'%49$.'6$)."%4C'LSU')98)3)#&%*'+$9'+$"*4'$'5$9A4%&"*'

5FX'*8&".5'9&#'34'-.$+45'&9'$9'LSU')98)3)#&%'"9.4**'-&#$**)":'.4@4.*'

PROTOCOL 4.5 Beta-Blocker Titration in Cardiomyopathy


+$9'34'4$*).7':&9)#&%45'$#'%4A".$%')9#4%@$.*>'LSU')98)3)#&%*'$.*&'+$"*4'3)%#8'5464+#*'$95'*8&".5'94@4%'34'"*45')9'<&:49'<8&'$%4'-%4A9$9#>'F)P4'34#$23.&+P4%*C'LSU')98)3)#&%*'+$9'+$"*4'.&<'3.&&5'-%4**"%4'$95'*8&".5'34'$@&)545')9'-$#)49#*'<)#8'$'*7*#&.)+'3.&&5'-%4**"%4'.4**'#8$9'g1'::,A>'

PROTOCOL 4.6'-%&@)54*'A")5$9+4'&9'#)#%$#)&9'&6'LSU')98)3)#&%*')9'+$%5)&2:7&-$#87>'

4.8.3.3 Hydralazine and Isosorbide Dinitrate,75%$.$^)94')*'$9'$%#4%)&.$%'5).$#&%C'$95')*&*&%3)54'5)9)#%$#4')*'$'@49&5)2.$#&%>'_849'"*45')9'+&:3)9$#)&9C'#847'8$@4'3449'*8&<9')9'.$%A4'+.)9)+$.'#%)$.*'#&'54+%4$*4'#84'%)*P'&6'54$#8'37'$3&"#'B1m'$95'):-%&@4'84$%#'6$).2"%4'*7:-#&:*C'$.#8&"A8'#847'$%4'9&#'$*'4664+#)@4'$*'LSU')98)3)#&%*>Bg2K1',75%$.$^)94'$95')*&*&%3)54'8$@4'#84'$5@$9#$A4'&6'$664+#)9A'84$%#'%$#4'$95'%49$.'6"9+#)&9'.4**'#8$9'34#$23.&+P4%*'$95'LSU')98)3)#&%*>'H847'$%4'*$64'#&'"*4'<849'3%$57+$%5)$'.):)#*'34#$23.&+P4%'"*4'$95i&%'<849'%49$.'6"9+#)&9'-%&8)3)#*'LSU')98)3)#&%'"*4>',&<4@4%C'#8)*'5%"A'+&:3)9$#)&9')*'4E-49*)@4C')#'%4O")%4*')9+&9@49)49#'#8%442#):4*2$25$7'5&*)9AC'$95')#'

-$#)49#'$584%49+4>'[&%'#84*4'%4$*&9*C'<4'A494%$..7'%4*4%@4'#84'"*4'&6'875%$.$^)94i)*&*&%3)54'5)9)#%$#4'6&%'-$#)49#*'<)#8'+&9#%$)95)+$#)&9*'#&'34#$23.&+P4%*'$95i&%'LSU')98)3)#&%*>'L*'<)#8'&#84%'84$%#'6$)."%4':45)+$2#)&9*C'+$"#)&9'*8&".5'34'4E4%+)*45'<849'*#$%#)9A'&%')9+%4$*)9A'#84*4':45)+$#)&9*')9'-$#)49#*'<8&*4'3.&&5'-%4**"%4')*'.4**'#8$9'd1'::,A>'

PROTOCOL 4.6'$.*&'-%&@)54*'A")5$9+4'&9'#)#%$#)&9'&6'875%$.$^)94i)*&*&%23)54')9'+$%5)&:7&-$#87>

NO

YES

YES NO

NO

YESNO

NO

YES

NO

YES

YESNO

IncreaseACE inhibitor(Table 4.15)

Creatinine ≥ 200 µmol/L

AND/OR K ≥ 5.5 mEq/L?

Start,continue or

increasehydralazine

andisosorbidedinitrate

(Table 4.15)

Stop/donot start

ACEinhibitors

MaintainACE inhibitor

dose

SBP ≥ 90 mmHg

SBP ≤ 90

mmHg

Decrease/do not start

ACE inhibitor

Wait to start ordecrease

hydralazineand isosorbide

dinitrate(Table 4.15)

Able to checkcreatinine AND/OR

potassium?Pregnant

K ≥ 6.5 mEq/L

Admit, treathyperkalemia(Section 6.5)

Decrease or maintain ACE inhibitor

Cardiomyopathy, diuretic and beta-blocker adjustments made

At ACE inhibitor

goal dose OR increasing beta-blocker?


PROTOCOL 4.6 ACE-Inhibitor Titration and Use of Hydralazine/Isosorbide in Cardiomyopathy

4.8.3.4 SpironolactoneL*'54*+%)345')9'SECTION 4.7.3C'*-)%&9&.$+#&94'+$9'34'$'"*46".'$5D"9+#)@4'5)"%4#)+')9'+$*4*'&6'$*+)#4*>'F)P4'LSU')98)3)#&%*C'*-)%&9&.$+#&94'+$9'+$"*4'$'%)*4')9'*4%":'-&#$**)":C'4*-4+)$..7')9'#84'-%4*49+4'&6'%49$.'6$)."%4>''?#'*8&".5'34'$@&)545')6'#84'+%4$#)9)94'.4@4.')*'A%4$#4%'#8$9'J11'n:&.iF'

<)#8'+8%&9)+$..7'.&<'-&#$**)":'*4+&95$%7'#&'#84'"*4'&6'6"%&*4:)54'&%'875%&+8.&%&#8)$^)54>'Y-)%&9&.$+#&94'8$*'$.*&'3449'*8&<9'#&'%45"+4':&%#$.)#7'37'B1m')9'-$#)49#*'<)#8'.46#'@49#%)+".$%'57*6"9+#)&9'<8&'$%4'$.%4$57'#$P)9A'LSU')98)3)#&%*>K/CKJ'TABLE 4.15'*8&<*'%4+&::49545'5&*)9A>

YES

NO

YES

YES

YES

NO

NO

NO

NO

NO

YES

NO

YES

YES

YES

Refer tofamily

planning

Womanbetween 15 and 49

years

PeripartumCMP?

Aspirin

HIV?

Refer toinfectious

diseaseclinic

AlcoholCMP?Abstinence

Spironolactone(Table 4.15)

Atrialfibrillation by

ECG

Start warfarin(see Chapter 5)

Irregularheart rhythm

ClassIII or IV

symptomsDigoxin

(Table 4.16)

Patient with cardiomyopathy, diuretic, beta-blocker and ACE inhibitor/hydralazine/isosorbide adjustments made

Ascites OR

K ≤ 3.5 mEq AND Cr ≤ 100 µmol/L AND SBP ≥ 90


4.8.4 Other Medications in Cardiomyopathy Management(4-495)9A'&9'#84'*"*-4+#45'4#)&.&A7'&6'+$%5)&:7&-$#87'$95i&%'5)*4$*4'+&6$+#&%*C'+4%#$)9'$5D"9+#)@4':45)+$#)&9*':$7'34')95)+$#45>'PROTOCOL 4.72-%&@)54*'A")5$9+4'&9'"*)9A'#84*4'&#84%':45)+$#)&9*>'

PROTOCOL 4.7 Other Medication Needs for Cardiomyopathy Patients


TABLE 4.16 Digoxin Dosing

Starting dose Maximum dose

0.125 mg/day 0.25 mg/day

4.8.4.1 Digoxin (Digitalis)()A&E)9')*'&94'&6'#84'&.54*#'$95':&*#'<)54.7'$@$).$3.4':45)+$#)&9*'6&%'#84'#%4$#:49#'&6'84$%#'6$)."%4>'?#'$+#*'#&')9+%4$*4'#84'-":-)9A'6"9+#)&9'

)*'-%4*49#>'a*)9A'5)A&E)9'+$9'):-%&@4'*7:-#&:*')9'-$#)49#*'<)#8'84$%#'6$)."%4>',&<4@4%C')9'$'.$%A4'+.)9)+$.'#%)$.C')#'5)5'9&#'54+%4$*4':&%#$.2)#7>KB'L.*&C'$#'8)A8'5&*4*C'#&E)+)#7'+$9'54@4.&-C'<8)+8'<)..'%4*".#')9'@)*"$.'+8$9A4*C'5)^^)94**C'&%'9$"*4$C'$95'+$9'.4$5'#&'5$9A4%&"*'$%%87#8:)$*>'H&E)+)#7'<)..'&++"%')6'5)A&E)9')*'"*45')9'-$#)49#*'<)#8'%49$.'6$)."%4C'*&'#8)*'

KK'_4'%4*4%@4'5)A&E)9'6&%'-$#)49#*'<)#8'+.$**'???'&%'?\'84$%#'6$)."%4'*7:-#&:*>'

84.-'<)#8'%$#4'+&9#%&.>'

TABLE 4.16'.)*#*'%4+&::49545'5)A&E)9'5&*)9A>

4.8.4.2 Aspirin_849'#84'84$%#'5&4*'9&#'-":-'<4..C'3.&&5'#495*'#&'*)#'*#)..')9*)54'#84'84$%#'$95':$7'6&%:'+.&#*C'<8)+8'+$9'#849'4:3&.)^4'V#%$@4.'#&'&#84%'-$%#*'&6'#84'3&57XC'+$"*)9A'*#%&P4'&%'&#84%'+$#$*#%&-8)+'4@49#*>'G4%)-$%#":'+$%5)&:7&-$#87'-$#)49#*'$%4'$#'-$%#)+".$%.7'8)A8'%)*P'6&%'#8)*C'$*'<4..'$*'6&%'@49&"*'+.&#*>'H847'*8&".5'34'*#$%#45'&9'/11':A'&6'$*-)%)9'5$).7'#&'84.-'#8)9'#84'3.&&5>'G$#)49#*'<)#8'4@)549+4'&6'$9'$+#)@4'+.&#'<)..'9445'*#%&9A4%'$9#)+&$A".$#)&9'V*44'CHAPTER 5X>

4.8.4.3 Birth ControlL..'64:$.4'-$#)49#*'&6'+8).534$%)9A'$A4'*8&".5'34'+&"9*4.45'&9'#84'5$92A4%*'&6'-%4A9$9+7')9'#84'*4##)9A'&6'$'+$%5)&:7&-$#87>'H84'-87*)&.&A)+'

*:$..4%'."9A'@&.":4*C':4$9'#8$#'84$%#'6$)."%4'*7:-#&:*'$.:&*#'$.<$7*'<&%*49>'?9'#84'+$*4'&6'-4%)-$%#":'+$%5)&:7&-$#87C'*"3*4O"49#'-%4A29$9+)4*'+$9'34'.4#8$.>'L..'<&:49'*8&".5'34'$5@)*45'#&'"*4'3)%#8'+&9#%&.>'S.)9)+)$9*'*8&".5'<&%P'<)#8'6$:).72-.$99)9A'*#$66'#&'+&&%5)9$#4'466&%#*'$95'49*"%4'#8$#'<&:49'$#'%)*P'%4+4)@4'#):4.7'$95'$--%&-%)$#4'3)%#8'+&9#%&.>'Y44'CHAPTER 3'6&%'6"%#84%'5)*+"**)&9'&6'3)%#8'+&9#%&.'6&%'<&:49'<)#8'84$%#'6$)."%4>'

4.8.4.4 Antiretrovirals (ARVs)a9#%4$#45',?\')964+#)&9'6%4O"49#.7'.4$5*'#&'+$%5)&:7&-$#87>K0CKZ'G%45)+2#&%*'&6',?\'+$%5)&:7&-$#87'$%4'&--&%#"9)*#)+')964+#)&9'$95'.49A#8'&6'


#):4'*)9+4',?\'5)$A9&*)*>'L..'-$#)49#*'<)#8'$'94<.7'5)$A9&*45'+$%5)&:72&-$#87'*8&".5'34'#4*#45'6&%',?\>'?6'$'-$#)49#')*',?\'-&*)#)@4C'%4A$%5.4**'&6'#84'S(K'+&"9#C'#84'-$#)49#'*8&".5'34'#%4$#45'<)#8'L;\*'$++&%5)9A'#&'.&+$.'-%&#&+&.*>

4.9 Hypertensive Heart Disease Etiology and Diagnosis

,7-4%#49*)&9'+%4$#4*'*#%4**'&9'#84'84$%#C'<8)+8'8$*'#&'<&%P'8$%54%'#&'-"*8'3.&&5')9#&'$'8)A82-%4**"%4'*7*#4:>'?9'%4*-&9*4'#&'#8)*'<&%P.&$5C'#84'84$%#':"*+.4'A4#*'#8)+P4%'V87-4%#%&-87X'$95'*#)664%>'H8)*'+8$9A4'542

<$..>'a*"$..7C'-$#)49#*'<)#8'87-4%#49*)@4'84$%#'5)*4$*4'<)..'8$@4'9&%:$.'&%'&9.7':).5.7'54-%4**45'*7*#&.)+'6"9+#)&9'V4D4+#)&9'6%$+#)&9'34#<449'K1m'$95'01mX'<)#8'.46#'@49#%)+".$%'87-4%#%&-87C'3"#'*&:4'+$9'-%&A%4**'#&'@4%7'.&<'4D4+#)&9'6%$+#)&9*>'

,7-4%#49*)@4'84$%#'5)*4$*4'%4*".#*'6%&:'.&9A2*#$95)9AC'*4@4%4'87-4%#492*)&9>'H84'87-4%#49*)&9')#*4.6':$7'34')5)&-$#8)+'V<8)+8')*':&*#'+&::&9X'&%'*4+&95$%7'#&'$9&#84%'-%&3.4:'V*"+8'$*'$'P)5947'&%'495&+%)94'5)*2

*"*-4+#45o*4@4%4'%49$.'6$)."%4')9'-$%#)+".$%o$.#8&"A8'87-4%#49*)&9')#*4.6'+$9'+$"*4'%49$.'6$)."%4>'

H%4$#:49#'&6'87-4%#49*)@4'84$%#'5)*4$*4')9+."54*'+&9#%&.'&6'@&.":4'*#$2#"*'$95'3.&&5'-%4**"%4>'PROTOCOL 4.82-%&@)54*'$9'&"#.)94'6&%'87-4%#492*)@4'84$%#'5)*4$*4':$9$A4:49#>

Suspected or confirmedhypertensive heart disease

Assess fluid status,adjust furosemide dose

(Protocol 4.3, Tables 4.9 and 4.12)

Assess blood pressureand adjust hypertensive

medications(Protocol 4.9)

Follow-upplanning

(Section 4.13,Table 4.23)

Assessmedication

contraindicationsand side e!ects(Protocol 4.10)


PROTOCOL 4.8 Management of Suspected or Confirmed Hypertensive Heart Disease

4.9.1 Vital Sign AssessmentL*'<)#8'$..'#7-4*'&6'84$%#'6$)."%4C':$9$A4:49#'&6'87-4%#49*)@4'84$%#'5)*4$*4'34A)9*'<)#8'$9'$**4**:49#'&6'#84'-$#)49#=*'@)#$.'*)A9*'$95'&@4%$..'+&95)#)&9>'(4+&:-49*$#)&9')9'-$#)49#*'<)#8'87-4%#49*)@4'84$%#'5)*4$*4'

%4*".#)9A')9'*#)6649)9A'&6'#84'84$%#>'L*'54*+%)345')9'CHAPTER 8C'#84'$--%&$+8')9'#8)*'*)#"$#)&9')*'#&'.&<4%'#84'3.&&5'-%4**"%4'A%$5"$..7o'

4.9.2 Fluid Status AssessmentH84'94E#'*#4-')9'#84':$9$A4:49#'&6'87-4%#49*)@4'84$%#'5)*4$*4')*'#84'

SECTION 4.7C'TABLE 4.9C'$95'PROTOCOL 4.3>

4.9.3 Titration of Antihypertensives?9'&%54%'#&'-%4@49#'<&%*49)9A'84$%#'6$)."%4'*7:-#&:*C'$9#)87-4%#492


TABLE 4.17 Antihypertensives for Hypertensive Heart Disease

First-line drug (ACE inhibitor)

Initial dose Dose increase Maximum dose

Side e"ects/cautions

Lisinopril 5 mg 1x/day 5 mg 1x/day 20 mg 1x/day 1. Birth defects (contraindicated in pregnancy)2. Chronic non-productive cough3. High potassium4. Worsened renal function


Second-line drug (thiazide)



Hydrochlorothiazide 12.5 mg 1x/day 12.5 mg 1x/day 25 mg 1x/day Lowers potassium

Third-line drug (CCB)*



Amlodipine 5 mg 1x/day 5 mg 1x/day 10 mg 1x/day Lower-extremity swelling

Nifedipine (sustained release)

20 mg 2x/day 20 mg 2x/day 40 mg 2x/day

Fourth-line drug (beta-blocker)



Atenolol 25 mg 1x/day 25 mg 1x/day 50 mg 1x/day 1. Bradycardia2. Renally excreted 3. Decrease dose for renal failure

Fifth-line drug (vasodilator)



Hydralazine 25 mg 3x/day 25 mg 3x/day 50 mg 3x/day 1. Headache2. Tachycardia3. Lower-extremity swelling

* CCB = Calcium-channel blocker

Y44'PROTOCOL 4.9C'PROTOCOL 4.10C'$95'TABLE 4.17>'?9'A494%$.C'$9'LSU'

4E)*#>'?6'#84'3.&&5'-%4**"%4')*'9&#'+&9#%&..45'&%')6'LSU')98)3)#&%*'$%4'9&#'$--%&-%)$#4'6&%'#84'-$#)49#C'$'#8)$^)54'5)"%4#)+':$7'34'*#$%#45>'L6#4%'#8$#C'$:.&5)-)94C'$'-4%)-84%$..7'$+#)9A'+$.+)":2+8$994.'3.&+P4%C'*8&".5'34'"*45>'!4#$23.&+P4%*'$95'875%$.$^)94'$%4'#8)%52'$95'6&"%#82.)94':45)+$2#)&9*C'%4*-4+#)@4.7>

YES

NO

YES

NO

YES

NO

YES

BP ≥160/100mmHg

Add 2 drugs ORincrease 2 drug dosesif already on 4 drugs

Add 1 drug ORincrease 1 drug doseif already on 4 drugs

BP ≥ 130/80≤ 160/100

mmHg

BP ≥ 90/70

BP ≤ 90/70

≤ 130/80mmHg

mmHg

Maintain currentmedications

Decrease currentmedications

Hypertensive heart diseasediuretic dose adjustments already made


PROTOCOL 4.9 Antihypertensive Management in Hypertensive Heart Disease

YES

YES

YES

NO

NO

Pregnant,Cr ≥ 200 µmol/L

AND/OR K ≥ 5.5 mEq/L?

Stop or do not startcaptopril/lisinopril AND/OR

spironolactone.

HR ≤ 50bpm?

Reduce, stop or do not startbeta-blocker

K ≥ 6.5mEq/L

Admit, treathyperkalemia(Section 6.5)

Suspected or confirmed hypertensiveheart disease, diuretic and

anti-hypertensive adjustments made


PROTOCOL 4.10 Assessment of Medication Contraindications and Side E"ects in Management of Hypertensive Heart Disease

4.10 Mitral Stenosis

R)#%$.'*#49&*)*')*'$'*-4+)$.'#7-4'&6'@$.@".$%'5)*4$*4'<)#8'$'#%4$#:49#'-$#8<$7'#8$#'5)664%*'6%&:'#8$#'&6'&#84%'@$.@".$%'5)*4$*4*>'a9#%4$#45C':)#%$.'*#49&*)*'.4$5*'#&'.46#'$#%)$.'49.$%A4:49#C'-".:&9$%7'87-4%#49*)&9C'$95'%)A8#'@49#%)+".$%'6$)."%4>'H84'*#%4#+845'.46#'$#%)":')*'-$%#)+".$%.7'-%&94'#&'54@4.&-)9A'4.4+#%)+$.'$39&%:$.)#)4*C'.4$5)9A'#&'$#%)$.'$%%87#82:)$*>'R)#%$.'*#49&*)*'$.:&*#'$.<$7*'%4*".#*'6%&:'"9#%4$#45'%84":$#)+'84$%#'5)*4$*4>'R)#%$.'*#49&*)*')*':&*#'+&::&9')9'-4&-.4'34#<449'B1'$95'01'74$%*'&.5'V$.#8&"A8')#':$7'*&:4#):4*'&++"%')9'7&"9A4%'&%'&.54%'-$#)49#*X>'b6#49'<&:49'<)..'54@4.&-'*7:-#&:*')9'#84':)55.4'&6'#84)%'-%4A9$9+)4*>'G$#)49#*'<)#8':)#%$.'*#49&*)*'$%4'$.*&'$#'8)A8'%)*P'&6'$#%)$.'

25)&A%$-87'+$9'4$*).7')549#)67'$'*#49&#)+':)#%$.'@$.@4C'<8)+8'8$*'$'8)A8.7'%4+&A9)^$3.4'-$##4%9')9'#84'-$%$*#4%9$.'.&9A'@)4<>'

YES

YES

NO

YES

YES

NO

NO

NO

NO

YES

HR ≥ 60bpm andSBP ≥ 90mmHg?

Start/increaseatenolol if not

contraindicated(Table 4.10)

Atrialfibrillation(on ECG)

AND/OR priorstroke

Aspirin 100mg 1x/day

Start warfarin iffeasable and notcontraindicated,

otherwise give aspirin(Chapter 5)

Suspected RHD and

≤ 40 years old?

Refer tofamily planning(Section 3.5)

Penicillinprophylaxis(Table 9.5)

Female, agebetween 15

and 49?

Mitralstenosis

Assess fluid status,adjust furosemide dose

(Protocol 4.3, Tables 4.9 and 4.12)

Assess vital signs and clinicalstatus. Treat and refer

decompensated heart failure

Surgical candidate?


Surgical planning(Chapter 5)


R)#%$.'*#49&*)*'%4O")%4*'$'5)664%49#'#%4$#:49#'*#%$#4A7'#8$9'&#84%'6&%:*'&6'@$.@".$%'84$%#'5)*4$*4>'H84'A&$.*'&6':45)+$.'#84%$-7'$%4'#&':$9$A4'

+$%5)$+'&"#-"#'37'+&9#%&..)9A'84$%#'%$#4>'PROTOCOL 4.11'&"#.)94*'#84'*#4-*')9'#84':45)+$.':$9$A4:49#'&6':)#%$.'*#49&*)*>'

PROTOCOL 4.11 Management of Mitral Stenosis


4.10.1 Vital Sign AssessmentL*'<)#8'$..'#7-4*'&6'84$%#'6$)."%4C':)#%$.'*#49&*)*':$9$A4:49#'34A)9*'<)#8'$9'$**4**:49#'&6'#84'-$#)49#=*'@)#$.'*)A9*'$95'&@4%$..'+&95)#)&9>'G$#)49#*'<)#8':)#%$.'*#49&*)*'$%4'-$%#)+".$%.7'*49*)#)@4'#&'#$+87+$%5)$'$95'<)..'9&#'34'$3.4'#&'#&.4%$#4'6$*#'84$%#'%$#4*'<4..>

4.10.2 Fluid Status Assessment

*#$#"*'$95'#)#%$#)&9'&6'5)"%4#)+*>'H84'-%)9+)-.4*'84%4'$%4'#84'*$:4'$*')9'&#84%'6&%:*'&6'84$%#'6$)."%4>'Y44'SECTION 4.7C'TABLE 4.9C'$95'PROTOCOL 4.3>

4.10.3 Control of Heart Rate_849'#84':)#%$.'@$.@4'5&4*9=#'&-49'<4..C'.4**'3.&&5'+$9':&@4'6%&:'#84'.46#'$#%)":'#&'#84'.46#'@49#%)+.4'5"%)9A'5)$*#&.4>'H8)*C')9'#"%9C'54+%4$*4*'#84'$:&"9#'&6'3.&&5'#84'84$%#'+$9'-":-'&"#'<)#8'4$+8'34$#>'_849'#84'

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6$*#'84$%#'%$#4*>'G$#)49#*'<)#8':)#%$.'*#49&*)*'$%4'"9$3.4'#&'#&.4%$#4'#84*4'6$*#'84$%#'%$#4*'$95'<)..'34+&:4'@4%7'*)+P'&%'4@49'5)4')6'#84'$%%87#8:)$'

$95':)#%$.'*#49&*)*'+$99&#'34'&3#$)945'<)#8'34#$23.&+P4%*'$.&94C'&%')6'3.&&5'-%4**"%4'.):)#*'#84'"*4'&6'34#$23.&+P4%*C'+.)9)+)$9*':$7'-%4*+%)34'

TABLE 4.18'$95'SECTION 4.16.1>X

TABLE 4.18 Medications to Reduce Heart Rate in Mitral Stenosis

Medication Initial dose Dose increase Maximum dose

Beta-blocker (for use in sinus tachycardia or atrial fibrillation)

Atenolol 12.5 mg 1x/day 12.5 mg 1x/day 50 mg 1x/day

Digoxin (only if tachycardia and atrial fibrillation)

Digoxin 0.125 mg 1x/day 0.125 mg 1x/day 0.25 mg 1x/day


4.10.4 Other Medications in Management of Mitral Stenosis4.10.4.1 Penicillin;84":$#)+'84$%#'5)*4$*4'+$"*4*'$.:&*#'$..'+$*4*'&6':)#%$.'*#49&*)*')9'%4*&"%+42-&&%'*4##)9A*>'L*'54*+%)345')9'CHAPTER 9C'-%4@49#)&9'&6'6"%#84%'$##$+P*'&6'%84":$#)+'64@4%'#8%&"A8'-49)+)..)9'-%&-87.$E)*'84.-*'*.&<'#84'-%&A%4**)&9'&6'%84":$#)+'@$.@".$%'5)*4$*4>'L.#8&"A8'%84":$#)+'64@4%'A494%$..7'$664+#*'*+8&&.2$A45'+8).5%49C'<4'%4+&::495'-49)+)..)9'-%&-87.$E)*'6&%'$..'-$#)49#*'<)#8'%84":$#)+'@$.@".$%'5)*4$*4'"954%'#84'$A4'&6'K1>'Y44'SECTION 9.2$95'$5:)9)*#%$#)&9>'

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4.11 Other Valvular and Congenital Heart Disease

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H8)*'+&..4+#)&9'&6'84$%#'6$)."%4'5)$A9&*4*')*'3&#8'.$%A4%'$95':&%4'5)@4%*4'#8$9'#84'-%4@)&"*'+$#4A&%)4*>',&<4@4%C'#84*4'5)*4$*4*'*8$%4'$'+&::&9'-$#8<$7')9'#84)%')9)#)$.':45)+$.':$9$A4:49#>'R&%4&@4%C'5)664%49#)$#)&9'$:&9A'#84*4'5)*4$*4*'&6#49'%4O")%4*'$'8)A84%'.4@4.'&6'4+8&+$%5)&A%$-8)+'$95'&#84%'5)$A9&*#)+'*P)..*'#8$9'$%4'%4$*&9$3.7'$##$)9$3.4'37'A494%$.)*#'-87*)+)$9*'&%'$5@$9+45'9"%*4*')9'%4*&"%+42-&&%'*4##)9A*>

H84'+&::&9'A&$.*')9'#84':45)+$.':$9$A4:49#'&6'#8)*'A%&"-'&6'84$%#'

5)*4$*4'<)..'34'*"%A)+$.C'$95'#8"*'$..'-$#)49#*'*"664%)9A'#8)*'+.$**'&6'84$%#'6$)."%4'*8&".5'34'4@$."$#45'37'$'+$%5)&.&A)*#'&%'4E-4%)49+45')9#4%9)*#'&%'-45)$#%)+)$9'<)#8)9'Z'<44P*'#&'Z':&9#8*'&6'5)$A9&*)*>

NO

YES

Suspected or echocardiographically confirmedvalvular or congenital heart disease.

No evidence of mitral stenosis

Assess fluid status, adjust diuretic(Protocol 4.3, Tables 4.9 and 4.12)

Surgicalcandidate?



Assess creatinine, potassium andneed for ACE inhibitor

(Protocol 4.13)

Follow-up, surgical planning,consultation with a

cardiologist



PROTOCOL 4.12 Valvular or Congenital Heart Disease Management (Excluding Mitral Stenosis)

4.11.1 Vital Sign AssessmentL*'<)#8'$..'#7-4*'&6'84$%#'6$)."%4C':$9$A4:49#'&6'#8)*'+&..4+#)&9'&6'84$%#'6$)."%4'#7-4*'34A)9*'<)#8'$9'$**4**:49#'&6'#84'-$#)49#=*'@)#$.'*)A9*'$95'&@4%$..'+&95)#)&9>

4.11.2 Fluid Status Assessment

&6'5)"%4#)+*>'Y44'SECTION 4.7C'TABLE 4.9C'$95'PROTOCOL 4.3>

NO

YES

NOYES

YES YES

NO

NO

Pregnant,creatinine ≥ 200µmol/L AND/ORK ≥ 5.5 mEq/L?

K ≥ 6.5 mEq/L

Able to checkcreatinine AND/OR

potassium?

SBP ≤ 100mmHg

Stop/do notstart ACEinhibitors

AtACE inhibitor

goal dose

MaintainACE inhibitor

dose

Valvular or congenitaldisease, diuretic

adjustments made

IncreaseACE inhibitor

Treat forhyperkalemia

(see Section 6.5)


4.11.3 Titration of ACE Inhibitors ?9'-$#)49#*'<)#8'@$.@".$%'84$%#'5)*4$*4'V4E+."5)9A':)#%$.'*#49&*)*XC')#')*'):-&%#$9#'#&'%45"+4'#84'<&%P.&$5'&6'#84'84$%#'37'.&<4%)9A'#84'3.&&5'-%4**"%4>'H84'84$%#'<$*'54*)A945'#&'-":-'3.&&5')9'&9.7'&94'5)%4+#)&9>'

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k/J1'::,A>'PROTOCOL 4.13'&"#.)94*'$9'$--%&$+8'#&')9)#)$#)9A'$95'#)#%$#)9A'LSU')98)3)#&%*>'

PROTOCOL 4.13 ACE-Inhibitor Titration for Valvular or Congenital Heart Disease Management (Excluding Mitral Stenosis)


4.11.4 Other Medications4.11.4.1 SpironolactoneG$#)49#*'<)#8'5)*4$*4'&6'$97'&6'#84'@$.@4*'&9'#84'%)A8#'*)54'&6'#84'84$%#'+$9'54@4.&-'*7:-#&:*'&6'%)A8#'84$%#'6$)."%4C')9+."5)9A':$**)@4'$*+)#4*>'?9'#84*4'-$#)49#*C'*-)%&9&.$+#&94'+$9'34'$'"*46".'$5D"9+#'#&'6"%&*4:)54'V*44'TABLE 4.19X>'Y-)%&9&.$+#&94'*8&".5'9&#'34'"*45')9'-$#)49#*'<)#8'

87-4%P$.4:)$>'S&9+"%%49#'"*4'<)#8'$9'LSU')98)3)#&%'+$9'$.*&'+$"*4'5$9A4%&"*'87-4%P$.4:)$C'$95'#84*4'-$#)49#*'*8&".5'8$@4'-&#$**)":':&9)#&%45'4@4%7'*)E':&9#8*>'

4.11.4.2 PenicillinL*'54*+%)345')9'CHAPTER 9C'-49)+)..)9'-%&-87.$E)*'84.-*'*.&<'#84'-%&2A%4**)&9'&6'%84":$#)+'@$.@".$%'5)*4$*4'37'-%4@49#)9A'6"%#84%'$##$+P*'&6'%84":$#)+'64@4%>'L.#8&"A8'%84":$#)+'64@4%'A494%$..7'$664+#*'*+8&&.2$A45'+8).5%49C'<4'%4+&::495'-49)+)..)9'-%&-87.$E)*'6&%'$..'-$#)49#*'<)#8'%84":$#)+'@$.@".$%'5)*4$*4'"954%'#84'$A4'&6'K1>'Y44'SECTION 9.2'6&%'*-42

TABLE 4.19 Medications for Valvular/Congenital Heart Disease

Initial dose Dose adjustment Maximum dose

ACE inhibitor

Lisinopril 5 mg 1x/day 5 mg 1x/day 20 mg 1x/day


Potassium-sparing diuretic

Spironolactone 12.5–25 mg 1x/day 12.5 mg 1x/day 25 mg 1x/day

YES

NO

YES

YES

NO

NO YES

YES

Refer to familyplanning

(Section 3.5)

Woman between 15

and 49 years

Suspected RHD andage ≤ 40

Penicillinprophylaxis(Table 9.5)

AscitesAND

K ≤ 3.5 mEq/L ANDCr ≤ 100 µmol/LAND SBP ≥ 90

mmHg

Startspironolactone

(Table 4.15)

Patient with congenital or valvular disease(excluding mitral stenosis) and

diuretic, ACE-inhibitor adjustments made

Atrial fibrillationby ECG

Protocol 4.9

Irregular heart rate

NO


PROTOCOL 4.14 Other Medications for Valvular or Congenital Heart Disease Management (Excluding Mitral Stenosis)

4.11.5 Cardiac Surgery Evaluation

34'*"%A)+$.C'$95'#8"*'$..'-$#)49#*')9'#8)*'+.$**'&6'84$%#'6$)."%4'*8&".5'34'4@$."$#45'37'$'+$%5)&.&A)*#'&%'4E-4%)49+45')9#4%9)*#'<)#8)9'Z'<44P*'#&'Z':&9#8*'&6')9#$P4>'L.#8&"A8'$5@$9+45'4+8&+$%5)&A%$-87')*'9&#'944545'#&'A")54':45)+$.':$9$A4:49#'&6'#84'-$#)49#C')#')*'94+4**$%7'#&'4@$."$#4'#84'

+&:-49*$#45':$7'34'+$95)5$#4*'6&%'*"%A)+$.')9#4%@49#)&9'346&%4'#847'


34A)9'#&'54+&:-49*$#4>'L#'#):4*C'#84*4'$%4'#84'34*#'*"%A)+$.'+$95)5$#4*>'Y44'CHAPTER 5'6&%':&%4'54#$).'&9'+$%5)$+'*"%A4%7'4@$."$#)&9>'

4.12 Right-Sided Heart Failure Etiology and Diagnosis

H84'#4%:*'%)A8#2'$95'.46#2*)545'84$%#'6$)."%4'$%4'&6#49'"*45'#&'54*+%)34'$'-$#)49#=*'-%4*49#)9A'*7:-#&:*>'R&*#'4#)&.&A)4*'&6'84$%#'6$)."%4'+$9'%4*".#'6%&:'.46#2*)545'84$%#'6$)."%4'*7:-#&:*'V*"+8'$*'*8&%#94**'&6'3%4$#8'$95'&%#8&-94$XC'$95'-$#)49#*'<)#8'*)A9*'&6'.46#2*)545'84$%#'6$)."%4'<)..'&6#49'8$@4'*)A9*'&6'%)A8#2*)545'84$%#'6$)."%4>',&<4@4%C'-$#)49#*'<)#8')*&.$#45'*7:-#&:*'&6'%)A8#2*)545'84$%#'6$)."%4'V$*+)#4*C'84-$#&:4A$.7C'4.4@$#45'D"A".$%'@49&"*'-%4**"%4'vI\GwC'.&<4%'4E#%4:)#7'454:$X'6$..')9#&'$'5)*#)9+#'+$#4A&%7'&6'5)$A9&*4*>'VY44'TABLE 4.20>X

?9'%4*&"%+42-&&%'*4##)9A*'*"+8'$*';<$95$C')*&.$#45'%)A8#2*)545'84$%#'6$)."%4':&*#'&6#49'%4*".#*'6%&:'+8%&9)+'5)*4$*4*'&6'#84'."9A*'#8$#'8$@4'.45'#&'-".:&9$%7'87-4%#49*)&9'&%'6%&:'5)*4$*4*'&6'#84'-4%)+$%5)":'V*44'TABLE 4.21X>'H"34%+".&*)*')*'37'6$%'#84':&*#'+&::&9'%4$*&9'6&%'+&9*#%)+2#)@4'-4%)+$%5)$.'5)*4$*4')9':&*#'&6'%"%$.'*"32Y$8$%$9'L6%)+$C'$95'$*'*"+8'%4-%4*49#*'$'#%4$#$3.4'+$"*4'&6'84$%#'6$)."%4>

TABLE 4.20 Clinical Presentation of Right-Sided Heart Failure

Symptoms Physical exam findings

Weight gain Elevated JVP

Abdominal swelling Cardiac murmur (depending on cause)

Lower-extremity edema Enlarged or pulsatile liver

Decreased appetite Ascites

Right-upper-quadrant pain Lower-extremity pitting edema

V*"+8'$*'+$%5)&:7&-$#87C'87-4%#49*)@4'84$%#'5)*4$*4C':)#%$.'*#49&*)*C'$95'&#84%'@$.@".$%'5)*4$*4X'346&%4'+&9*)54%)9A'-"%4'%)A8#2*)545'84$%#'6$)."%4'$*'$'5)$A9&*)*>'L*'<)#8'&#84%'+$#4A&%)4*'&6'84$%#'6$)."%4C'#84'-%42+)*4'5)$A9&*)*')*'94)#84%'4$*7'9&%'4**49#)$.'#&'#84')9)#)$.':$9$A4:49#'&6'#84'-$#)49#>'b"%'-%&#&+&.'6&%'%)A8#2*)545'84$%#'6$)."%4'#84%46&%4'6&+"*4*'&9'4E+."5)9A'9&92+$%5)$+'+$"*4*'&6'#84'-%4*49#)9A'*7:-#&:*'&6'454:$'

4:-)%)+'#"34%+".&*)*'#%4$#:49#>'

G$#)49#*'<)#8'$*+)#4*'+$"*45'37'.)@4%'6$)."%4'&%'%49$.'6$)."%4'+$9'%4*4:3.4'

5)*#)9A")*8'34#<449'#84*4'-$#)49#*>'U+8&+$%5)&A%$-87')*'4**49#)$.')9'5)664%49#)$#)9A'-$#)49#*'<)#8'%)A8#2*)545'84$%#'6$)."%4'6%&:'#8&*4'<)#8'&#84%'4#)&.&A)4*'&6'454:$'$95'$*+)#4*>'?9'-$%#)+".$%C'4+8&+$%5)&A%$-87'


+$9'34'84.-6".'$*'$'<$7'#&'4E+."54'84$%#'6$)."%4'$*'$'+$"*4'&6'$*+)#4*>'?6'#84'-$#)49#'8$*'9&':"%:"%*'$95'8$*'$9'49#)%4.7'9&%:$.2$--4$%)9A'3$*)+'4+8&+$%5)&A%$:'V)9+."5)9A'$'9&%:$.')964%)&%'@49$'+$@$'$95'%)A8#'@49#%)+.4XC'#847'$%4'"9.)P4.7'#&'8$@4'$'+$%5)$+'+$"*4'&6'#84)%'-%4*49#)9A'*7:-#&:*'V*44'FIGURE 4.5'$95'FIGURE 4.8X>

)549#)67)9A'#8&*4'-$#)49#*'<8&'$%4'.)P4.7'#&'8$@4'5)*4$*4'+$"*45'37'$+2#)@4'#"34%+".&*)*>'G$#)49#*'<)#8'&#84%'#7-4*'&6'%)A8#'@49#%)+".$%'6$)."%4'

<)..'34':$)9.7'-$..)$#)@4'$95'<)..':)%%&%'#84'$--%&$+8'#&':45)+$.':$92$A4:49#'&6'-$#)49#*'<)#8'@$.@".$%'$95'&#84%'+&9A49)#$.'84$%#'5)*4$*4>'

PROTOCOL 4.15'&"#.)94*'$9'$--%&$+8'#&'-$#)49#*'<)#8')*&.$#45'%)A8#2*)545'84$%#'6$)."%4>

TABLE 4.21 Causes of Right-Sided Heart Failure

Cause Notes

Left-sided heart failure Left-sided heart failure is the most common cause of right-sided heart failure. Some common causes include cardiomyopathy, mitral stenosis, and mitral regurgitation

Tricuspid valve abnormalities Tricuspid valve stenosis, tricuspid regurgitation, congenital heart disease

Pulmonary disease Pulmonary TB, severe COPD

Pulmonary hypertension HIV, congenital heart disease (commonly VSD, ASD), other

Constrictive pericarditis Most commonly caused by TB

Endomyocardial fibrosis Cause unknown

NO

YES

Suspected or echocardiographically confirmedisolated right sided heart failure

Assess fluid status, adjust diuretic(Protocol 4.16)

Surgicalcandidate?



Assess creatinine, potassium andneed for ACE inhibitor

(Protocol 4.18)

Follow-up and consultationwith a cardiologist to confirm

diagnosis


Assess for tuberculosis pericarditis(Protocol 4.17)


PROTOCOL 4.15 Management of Isolated Right-Sided Heart Failure

4.12.1 Vital Sign AssessmentL*'<)#8'$..'#7-4*'&6'84$%#'6$)."%4C':$9$A4:49#'&6'*"*-4+#45'%)A8#2*)545'84$%#'6$)."%4'34A)9*'<)#8'$9'$**4**:49#'&6'#84'-$#)49#=*'@)#$.'*)A9*'$95'&@4%$..'+&95)#)&9>'G$#)49#*'<)#8'$9'466"*)&9'$95'87-&#49*)&9'*8&".5'34'-%4*":45'#&'8$@4'#$:-&9$54'$95'*8&".5'34'%464%%45'#&'#84'5)*#%)+#'8&*2-)#$.'6&%'4:4%A49#'-4%)+$%5)&+49#4*)*>'F)P4<)*4C'-$#)49#*'<)#8':$**)@4'$*+)#4*'#8$#')*'+$"*)9A'%4*-)%$#&%7'5)*#%4**'*8&".5'$.*&'34'%464%%45'#&'#84'5)*#%)+#'8&*-)#$.'6&%'-$%$+49#4*)*>

NO YES

Hypo-volemia (1)

Stop alldiuretics,consider

giving fluids

Perform volume assessment(definitions of fluid status di!erent than for

other types of heart failure)

Hyper-volemia

Moderate(3)

Severe(4)

Increasefurosemide

dose(Section 4.7.2)

IV diuresis,paracentesis,

hospitalize

Euvolemia(2)

Suspected or confirmedisolated right-heart failure

On ≤ 80 mgfurosemide

2x/day?

(1) Hypovolemia: Rising creatinine, low blood pressure; may still have significant edema or ascites(2) Euvolemia: Comfortable, able to perform daily activities(3) Hypervolemia, Moderate: Increasing ascites or edema, uncomfortable but able to do basic activities(4) Hypervolemia, Severe: Rapid breathing, unable to walk

Maintatin furosemidedose, consider adding

sprionolactone andACE inhibitor

(Protocol 4.18)


4.12.2 Fluid Status AssessmentH84'94E#'*#4-')9'#84':$9$A4:49#'&6'%)A8#2*)545'84$%#'6$)."%4')*'4@$."$2

-%&6&"95'.4A'454:$'$95'$*+)#4*>'?9':&*#'+$*4*C'#84*4'-$#)49#*'<)..'94@4%'%4$+8'4"@&.4:)$C'$95'$##4:-#)9A'#&'5)"%4*4'#84:'5&<9'#&'$'5%7'<4)A8#'<)..'%4*".#')9')9#%$@$*+".$%'87-&@&.4:)$C'+$"*)9A'%49$.'6$)."%4C'87-&#492*)&9C'$95'4.4+#%&.7#4'):3$.$9+4*>'H84'A&$.'*8&".5'34'#&':)9):)^4'#84'-$#)49#=*'5)*+&:6&%#'6%&:'454:$'$95'$35&:)9$.'5)*#49*)&9>'

L*'<)#8'&#84%'#7-4*'&6'84$%#'6$)."%4C'6"%&*4:)54')*'#84':$)9'#&&.'6&%'+&92SECTION 4.7.2>

Y-)%&9&.$+#&94'*8&".5'34'$5545'#&'$**)*#')9'5)"%4*)*'&6'-$#)49#*'<)#8'9&%:$.'%49$.'6"9+#)&9>'?9'-$#)49#*'<)#8'*4@4%4'5)*+&:6&%#'&%'%4*-)%$#&%7'5)*#%4**'6%&:'$*+)#4*C'-$%$+49#4*)*':$7'34'-4%6&%:45'V*44'SECTION 4.12.4X>

PROTOCOL 4.16 Fluid Status Management in Right-Sided Heart Failure


4.12.3 Pericardial Disease()*4$*4*'&6'#84'-4%)+$%5)":'6$..')9#&'#<&':$)9'+$#4A&%)4*W'V/X'-4%)+$%25)$.'466"*)&9*h'$95'VJX'+&9*#%)+#)@4'-4%)+$%5)$.'5)*4$*4>K]'!&#8'&6'#84*4'+&95)#)&9*'+$9'.4$5'#&'84$%#'6$)."%4'37'+$"*)9A'4E#4%9$.'+&:-%4**)&9'&9'

4.12.3.1 Pericardial E#usions2

$..'6&%:*'&6'84$%#'6$)."%4>',&<4@4%C'.$%A4'-4%)+$%5)$.'466"*)&9*'<)#8&"#'

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FIGURE 4.9X>'?6'.$%A4'49&"A8C'$'-4%)+$%5)$.'466"*)&9'+$9'+$"*4'.)642#8%4$#49)9A'87-&#49*)&9C'<8)+8')*'P9&<9'$*'+$%5)$+'#$:-&9$54>'

V-4%)+$%5)&+49#4*)*X>

4.12.3.2 Constrictive PericarditisH84'5)*4$*4*'#8$#'+$"*4'$'-4%)+$%5)$.'466"*)&9'+$9'$.*&'.4$5'#&'*+$%%)9A'$95'*#)6649)9A'&6'#84'-4%)+$%5)":>'H8)*')*'P9&<9'$*'+&9*#%)+#)@4'-4%)+$%2

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$@$).$3.4')9'+&::"9)#723$*45'*4##)9A*>'()$A9&*)*':"*#'#84%46&%4'34'3$*45'&9'+.)9)+$.'-%4*49#$#)&9')9'#84'+&9#4E#'&6'%)*P'6$+#&%*'6&%'H!'$95',?\>

4.12.3.3 Diagnosis and Treatment of Tuberculosis PericarditisG%&:-#')9)#)$#)&9'&6'$9#)2:7+&3$+#4%)$'#%4$#:49#'+$9'34'.)64*$@)9A')9'+$*4*'&6'H!'-4%)+$%5)#)*>'_4'#84%46&%4'*"AA4*#'#8$#'H!')*'#84'-%4*":45'5)$A9&*)*')9'+$*4*'&6'*"*-4+#45'+&9*#%)+#)@4'-4%)+$%5)$.'5)*4$*4>'_4'


%4+&::495'*#$%#)9A'4:-)%)+'#84%$-7')9'#84*4'+$*4*>'L..'-$#)49#*'*#$%#45'&9'H!'#%4$#:49#'*8&".5'8$@4'#8%44'*4#*'&6'*-"#":'+&..4+#45>'L..'-$2#)49#*'*#$%#45'&9'#%4$#:49#'*8&".5'$.*&'34'*449'37'$'+$%5)&.&A)*#'<8&'<)..'54+)54C')9'+&9D"9+#)&9'<)#8'#84')964+#)&"*'5)*4$*4'+.)9)+C'<84#84%'#&'+&9#)9"4'&%'*#&-'#84'$9#)2#"34%+".&*)*':45)+$#)&9*>

H%4$#:49#'&6'-4%)+$%5)$.'H!')*'#84'*$:4'$*'6&%'-".:&9$%7'H!'$95'+&9*)*#*'&6'$'K25%"A'%4A):49'A)@49'&@4%'Z':&9#8*W'J':&9#8*'&6'5$).7')*&9)$^)5C'%)6$:-)9C'-7%$^)9$:)54C'$95'4#8$:3"#&.C'6&..&<45'37'K':&9#8*'&6'5$).7')*&9)$^)5'$95'%)6$:-)9>'H84%4')*'9&'9445'#&'-%&.&9A'#84'+&"%*4'&6'#%4$#:49#>'H84'"*4'&6'+&%#)+&*#4%&)5*')*'+&9#%&@4%*)$.C'3"#')9'*4@4%$.'*#"5)4*C'#84'+&9+&:)#$9#'"*4'&6'-%459)*&94'<)#8'$9#)2H!'#84%$-7'8$*'3449'*8&<9'#&'%45"+4':&%#$.)#7'$95'#84'9445'6&%'*"%A)+$.')9#4%2@49#)&9*>KgCKd'_4'#84%46&%4'%4+&::495'-%4*+%)3)9A'$'*#4%&)5'#$-4%'6&%'-$#)49#*'#%4$#45'6&%'*"*-4+#45'#"34%+".&*)*'-4%)+$%5)#)*'V*44'TABLE 4.22X>'!4+$"*4'%)6$:-)9')9+%4$*4*'#84':4#$3&.)*:'&6'*#4%&)5*C'-%459)*&.&94')*'A)@49'$#'%4.$#)@4.7'8)A8'5&*4*'V$%&"95'/>0':AiPA'-4%'5$7X>

TABLE 4.22 Treatment of Tuberculous Pericarditis in Adults

Medication Dose Schedule

Isoniazid 300 mg once daily 26 weeks

Rifampin 600 mg once daily 26 weeks

Pyrazinamide 20–25 mg/kg once daily (max dose 2 g) 8 weeks

Ethambutol 15–20 mg/kg once daily (max dose 1.6 g) 8 weeks

Prednisolone (example for a 50–55 kg patient)

40 mg twice per day 4 weeks, followed by

20 mg twice per daily 4 weeks, followed by

10 mg twice per day 2 weeks, followed by

5 mg once daily 1 week

YES

NO

NO

YESVery large right

ventricle(Figure 4.8)

Suspected constrictive pericardial disease,diuretic adjustments made

ObtainCXR,

HIV testCXR or historysuggestive of

TB?

Sputum smears,start empiric TB

treatment

Sputum smears,start empiric TB

Treatment

Do not starttreatment

for TB


PROTOCOL 4.17 Diagnosis and Treatment of Tuberculosis Pericarditis

4.12.4 Titration of ACE Inhibitors and Spironolactone and Paracentesis

L*'54*+%)345')9'SECTION 4.11.4.1C'*-)%&9&.$+#&94'+$9'34'"*45')9'$55)#)&9'#&'6"%&*4:)54'VF$*)EX'6&%'-$#)49#*'<)#8'$*+)#4*>',&<4@4%C')#'*8&".5'9&#'

5FX>'_849'*-)%&9&.$+#&94')*'-%4*+%)345'$.&9A'<)#8'.)*)9&-%).C'#84'-$#)49#'*8&".5'34':&9)#&%45'6&%'87-4%P$.4:)$'$#'.4$*#'4@4%7'Z':&9#8*>'Y-)%&9&2.$+#&94':$7'34'$'"*46".'$5D"9+#')9'-$#)49#*'<)#8'+8%&9)+$..7'.&<'-&#$*2*)":'*4+&95$%7'#&'6"%&*4:)54'&%'875%&+8.&%&#8)$^)54'"*4>

G$#)49#*'<)#8'#49*4'$*+)#4*':$7'9445'-4%)&5)+'-$%$+49#4*)*'#&'%4.)4@4'$325&:)9$.'5)*+&:6&%#'&%'%4*-)%$#&%7'5)*#%4**>',&<4@4%C'<)#8&"#'+&%%4+#)&9'

2&@4%C'6%4O"49#'-$%$+49#4*)*'-"#*'-$#)49#*'$#'%)*P'6&%'-4%)#&94$.')964+#)&9*'$95'.&**'&6'-%&#4)9C'<8)+8'+$9')9'#"%9'<&%*49'#84'$*+)#4*>

L6#4%'$55)9A'*-)%&9&.$+#&94C'$9'LSU')98)3)#&%':$7'34'$5545'#&'#84'-$2#)49#=*'%4A):49C')6'%49$.'6"9+#)&9'$95'3.&&5'-%4**"%4'-4%:)#>'L*')9'&#84%'#7-4*'&6'84$%#'6$)."%4C'#84'LSU')98)3)#&%'+$9'84.-'%45"+4'#84'84$%#=*'<&%P.&$5>'?9'$55)#)&9C'-$#)49#*'<)#8'%)A8#2*)545'84$%#'6$)."%4'#495'#&'8$@4'8)A8'.4@4.*'&6'$.5&*#4%&94C'$95'#84'LSU')98)3)#&%C'.)P4'*-)%&9&.$+2#&94C'+$9'+&"9#4%$+#'#8)*>

NO

YES

NOYES

YES

NO

NO

YES

YES

Pregnant,Cr ≥ 200 µmol/L

AND/OR K ≥ 5.5 mEq/L

Able to checkcreatinine and/or potassium?

SBP ≤ 100mmHg

Stop/do notstart ACEinhibitors

K ≥ 6.5mEq/L

ACE inhibitorat goal dose

Maintain ACE inhibitor at current dose,

add spironolactone(Table 4.15)

Isolated right-sidedheart failure, furosemide

adjustments made

IncreaseACE inhibitor

Treat forhyperkalemia

(see Section 6.5)

Maintain or decreaseACE inhibitor AND/OR

spironolactone


PROTOCOL 4.18 ACE-Inhibitor and Spironolactone Titration and Paracentesis for Isolated Right-Sided Heart Failure

4.12.5 Other Medication NeedsG$#)49#*'<)#8')*&.$#45'%)A8#2*)545'84$%#'6$)."%4':$7'*"664%'6%&:'@$%)&"*'+&:&%3)5'+&95)#)&9*C'*&:4'&6'<8)+8':$7'34'%4.$#45'#&'&%'<&%*49'#84)%'84$%#'6$)."%4>'[&%')9*#$9+4C'-$#)49#*'<)#8',?\':$7'54@4.&-'-".:&9$%7'87-4%#49*)&9C'<8)+8'+$9'+$"*4'%)A8#2*)545'84$%#'6$)."%4>'_&:49'<)#8'%)A8#2*)545'84$%#'6$)."%4'*8&".5'$@&)5'34+&:)9A'-%4A9$9#C'$*'-%4A9$9+7'

*8&".5'34'%$#42+&9#%&..45'$95'$9#)+&$A".$#45>

YES

YES

NO

YES

NO

NOYES

Refer to familyplanning

(see Section 3.5)

Woman between 15

and 49 years

Patient with isolated right-sided heart failure;diuretic, ACE inhibitor adjustments made

Atrial fibrillationby ECG

Protocol 4.9

Irregularheart rate

HIVRefer to ID

clinic to startARVs


PROTOCOL 4.19 Other Medication Needs in Isolated Right-Sided Heart Failure

4.13 Heart Failure Patient Follow-Up

`&'84$%#'6$)."%4')9#4%@49#)&9'<)..'34'*"++4**6".'<)#8&"#'A&&5'-$#)49#'%4#49#)&9'$95'6&..&<2"->'CHAPTER 3'&"#.)94*'#84'):-&%#$9#'%&.4'+&::"29)#7'84$.#8'<&%P4%*'-.$7')9'#8)*'466&%#>'?9'$55)#)&9C'6%4O"49#':45)+$#)&9'$5D"*#:49#*'%4O")%4'6%4O"49#'+.)9)+'@)*)#*>'[%4O"49+7'&6'@)*)#*'*8&".5'34'

TABLE 4.23'-%&@)54*'#84'A")54'"*45'37'`S('+.)9)+)$9*')9'54#4%:)9)9A'8&<'&6#49'#&'*44'-$#)49#*')9'#84'+.)9)+>'b3@)&"*.7C'+.)9)+)$9*':"*#'%4.7'&9'#84)%'&<9'+.)9)+$.'D"5A:49#'<849'54#4%:)9)9A'8&<'6%4O"49#.7'$'-$#)49#'*8&".5'34'*449>'?9'A494%$.C'<4'49+&"%$A4'+.)9)+)$9*'#&'*44'-$#)49#*':&%4'6%4O"49#.7')6'#847'8$@4'$97'O"4*#)&9*'&%'+&9+4%9*'$3&"#'$'-$#)49#=*'+&95)#)&9'&%':$9$A4:49#>'H8)*'$..&<*'6&%'*:$..4%C':&%4'6%4O"49#'#)#%$#)&9'&6':45)+$#)&9*'$95'6$*#4%'%4+&A9)#)&9'&6'$'54#4%)&%$#)9A'+&95)#)&9>


TABLE 4.23 Clinic Follow-Up Schedule for Heart Failure Patients

Class I or Class II heart failure, euvolemic

Class III or Class IV symptoms, new renal failure, hypervolemic or any other clinical concern

Medication change Return in 2 weeks–1 month Return in 1–2 weeks

No medication change Return in 1–2 months Return in 2 weeks–1 month

?9'%"%$.C'%4*&"%+42-&&%'*4##)9A*'*"+8'$*';<$95$C'#%$@4.'#&'$'+.)9)+'+$9'

5)*#$9+4*>'L*'$'#4:-&%$%7':4$*"%4C'<4'8$@4'%45"+45'3$%%)4%*'#&'+.)9)+'$##495$9+4'37'-%&@)5)9A'#%$@4.'%4):3"%*4:49#'6&%'-$#)49#*'#%$@4.)9A'.&9A'5)*#$9+4*>

4.14 Potassium Management

R$97'&6'#84':45)+$#)&9*'"*45')9'84$%#'6$)."%4':$9$A4:49#'+$9'$664+#'-&#$**)":>'[&%')9*#$9+4C'-&#$**)":'.4@4.*':$7'54+%4$*4'&@4%'#84'+&"%*4'&6'5)"%4*)*>'S&9@4%*4.7C')6'-$#)49#*'8$@4'3$*4.)94'%49$.'57*6"9+#)&9C'-&#$**)":':$7'%)*4'#&'5$9A4%&"*'.4@4.*')6'%49$.'6"9+#)&9'<&%*49*>'G&#$**)":')*'$9'4**49#)$.'4.4+#%&.7#4'#8$#C'<849')9'):3$.$9+4C'+$9'+$"*4'

?9'A494%$.C'-&#$**)":'.4@4.*'<)..'9&#'34+&:4'5$9A4%&"*.7'8)A8'$*'.&9A'$*'+%4$#)9)94')*'9&%:$.>'R$97'6$+).)#)4*'$%4'$3.4'#&'+84+P'+%4$#)9)94'3"#'9&#'-&#$**)":>'L++&%5)9A.7C'<4'8$@4'3$*45'&"%'$.A&%)#8:*'&9'+%4$#)9)94'$.&94>'Y44'SECTION 6.5'6&%'5)*+"**)&9'&6':$9$A4:49#'&6'87-4%P$.4:)$>'

4.15 Arrhythmia Diagnosis and Management

G$#)49#*'<)#8'84$%#'6$)."%4'&6'$97'#7-4'$%4'$#')9+%4$*45'%)*P'&6'8$@)9A'2

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4.16 Role of Electrocardiography in Rural Rwanda

U.4+#%&+$%5)&A%$:'VUSTX'"*4')*'.):)#45'$#'%"%$.'5)*#%)+#'8&*-)#$.*')9';<$95$>'R$97'5)*#%)+#'8&*-)#$.*'5&'9&#'8$@4'$9'4.4+#%&+$%5)&A%$:':$+8)94C'$95'64<'5)*#%)+#'8&*-)#$.'+.)9)+)$9*'644.'+&:6&%#$3.4')9'#84'"*4'&%')9#4%-%4#$2#)&9'&6'UST*>'H84'A&$.')9';<$95$')*'#&'8$@4'$9'UST':$+8)94'$#'4$+8'5)*#%)+#'8&*-)#$.'$95'#&'-%&@)54'3$*)+'#%$)9)9A')9'UST')9#4%-%4#$#)&9>


H84':$)9'"#).)#7'&6'$9'UST')9'%"%$.';<$95$')*'#&'54#4+#'$%%87#8:)$*>'?9'#8)*'*4##)9AC'64<'-$#)49#*'8$@4'+&%&9$%7'$%#4%7'5)*4$*4C'$95'#84'$3).)#7'#&'54#4+#':7&+$%5)$.')96$%+#)&9'&9'UST')*'$'.4**'"*46".'*P)..>'

L.:&*#'$..'$%%87#8:)$*'&++"%'$:&9A'-$#)49#*'<)#8'84$%#'6$)."%4C'-$%2#)+".$%.7'$:&9A'#8&*4'<)#8'$'%45"+45'U['&%':)#%$.'*#49&*)*'$95'$:&9A'

+&::&9'$%%87#8:)$')9'#8)*'*4##)9A>'`S('+.)9)+)$9*'<)#8'9&'-%)&%'UST'#%$)9)9A'+$9'4$*).7'.4$%9'#&')549#)67')#*'+8$%$+#4%)*#)+'UST'-$##4%9>'b#84%'

#%4$#>'a96&%#"9$#4.7C':$97'-$#)49#*'<)#8'@49#%)+".$%'$%%87#8:)$*'94@4%':$P4')#'#&'#84'8&*-)#$.>'G$#)49#*'<)#8'+$%5)&:7&-$#87'$%4'$#'8)A8'%)*P'6&%'#84*4'#7-4*'&6'%87#8:*C'$95'34#$23.&+P4%'"*4'6&..&<)9A'#84'+$%5)&:72&-$#87'-%&#&+&.*'<)..'84.-'%45"+4'#8)*'%)*P>'[&%'#84*4'%4$*&9*C'<4'6&+"*'

<)#8'4*#$3.)*845'84$%#'6$)."%4>'

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4.16.1 Atrial Fibrillation Diagnosis and Management

+.)9)+)$9*'&3#$)9'$9'UST'&9'$97'-$#)49#'<)#8'$9')%%4A".$%'-".*4'&%'$'@4%7'

#84'UST')9'#84'+.)9)+'&%'$++&:-$97'#84'-$#)49#'#&'#84')9-$#)49#'<$%5'#&'8$@4'#84'UST'-4%6&%:45>'`S('9"%*4*'*8&".5'%4+4)@4'3$*)+'#%$)9)9A')9'UST')9#4%-%4#$#)&9>',&<4@4%C'$'5)*#%)+#'8&*-)#$.'-87*)+)$9'*8&".5'34'$@$).$3.4'#&'84.-'<)#8')9#4%-%4#$#)&9')6'#84%4'$%4'O"4*#)&9*>'H84'P47'UST'

VJX')%%4A".$%.7'*-$+45's;Y'<$@4*'V*44'FIGURE 4.10X>

A

º

A

P waves, regular (normal rhythm)

no P waves, irregular (atrial fibrillation)

P waves


FIGURE 4.10 ECG of Normal Rhythm (top) and Atrial Fibrillation (bottom)

G$#)49#*'<)#8'*)A9*'&6'54+&:-49*$#45'84$%#'6$)."%4'*8&".5'34'$5:)#2

%$#4C'4@49')6')#')*'$*7:-#&:$#)+C'*8&".5'$.*&'*#$7')9'#84'8&*-)#$.'"9#).'

*8&".5'8$@4'#84)%'84$%#'%$#4'.&<4%45')6'-&**)3.4>'F&<4%)9A'#84'84$%#'%$#4'

&"#-"#>'L*'$'A494%$.'%".4C'-$#)49#*'<)#8'$'*7*#&.)+'84$%#'%$#4'&@4%'/11'34$#*'-4%':)9"#4'*8&".5'%4+4)@4'$'#%)$.'&6'34#$23.&+P4%'#%4$#:49#>'()2A&E)9':$7'$.*&'34'A)@49'#&'84.-'*.&<'#84'84$%#'%$#4'$95')*'$'34##4%'+8&)+4')9'-$#)49#*'<)#8'3&%54%.)94'3.&&5'-%4**"%4*'$95i&%'*)A9*'&6'54+&:-492*$#45'84$%#'6$)."%4>'()A&E)9'A494%$..7'#$P4*'"-'#&'$'5$7'#&'#$P4'4664+#>'Y44'TABLE 4.18'6&%'5)A&E)9'5&*)9A>'

G$#)49#*'<)#8'54+&:-49*$#45'84$%#'6$)."%4C'$'.&<'*7*#&.)+'3.&&5'-%4*22

*)&9>'S$%5)&@4%*)&9':$+8)94*'*8&".5'34'$@$).$3.4'$#'$..'5)*#%)+#'8&*-)#$.*>'

22

#)&9'*8&".5'8$@4'$9'4+8&+$%5)&A%$:>'

$*7:-#&:$#)+'$%4'*#)..'$#'8)A8'%)*P'&6'*#%&P4'$95'*8&".5'34'$9#)+&$A"2.$#45>'CHAPTER 5'&"#.)94*')9)#)$#)&9'&6'<$%6$%)9'#84%$-7>'a9.)P4'-$#)49#*'<8&'$.%4$57'8$@4'+.&#*C'#84*4'-$#)49#*'5&'9&#'9445'#&'3%)5A45'<)#8'84-$%)9'#84%$-7'"9#).'#847'%4$+8'$'#84%$-4"#)+'?`;>

NO

YES

YES

YES

YES

NO

NO

NOAdmit to hospital,load with digoxin

(Table 4.18).If unstable, consider

cardioversion

SBP ≥ 100

mmHg

Lower heartrate with

beta-blockerand admit to

hospital

HR ≥ 120bpm

Patient with tachycardia (≥ 120 bpm) AND/ORirregular heart beat

Knownstructural

heartdisease

Initiateanticoagulation(see Chapter 5)

Obtain 12-leadECG to confirmatrial fibrillation

Atrial fibrillation(absence of P waves

and irregularly spacedQRS waves)

Start on aspirin 100 mgdaily, obtain an

echocardiogram

Likely sinus rhythm. If tachycardic, lookfor underlying cause (fever, pain, etc.)

and consider hospital admission


PROTOCOL 4.20 Diagnosis and Management of Atrial Fibrillation

4.17 Cardioversion

H84':$)9')95)+$#)&9'6&%'+$%5)&@4%*)&9')*'+$%5)&A49)+'*8&+P')9'#84'*4##)9A'

U@4%7'5)*#%)+#'8&*-)#$.'*8&".5'8$@4'$'+$%5)&@4%*)&9':$+8)94>'G$#)49#*'<8&'$%4'-&#49#)$..7')9'9445'&6'+$%5)&@4%*)&9'*8&".5'34'$5:)##45'#&'#84'8&*-)#$.'$95':$9$A45'37'#84')9-$#)49#'-87*)+)$9>

NO

YES

NO

NO

YES

YES

NO

YES

YES

YES

NO

NO

YES YES

NO

NO

Pulse ≥ 100 bpm orpauses or extra

beats by palpation?

Patient withpalpitations

Goiter?

Palpitationscurrently?

Fever?

Signs ofdehydration?

ECGavailable?

Check thyroidfunction testsand refer for

ECG

Work upinfection,consider

antibiotics

Murmur,edema,

orthopnea orexertionaldyspnea?

Investigate assuspected heart

failure(see Protocol 4.1)

Reassurepatient, stop any

cardiacmedications.Refer back toprimary care

Atenolol 12.5 mg1x per day or

propranolol 10mg 3x per day

Refer for ECG

No Pwaves orirregularrhythm?

Treat as atrialfibrillation (seeProtocol 4.20)

Look for andtreat underlying

cause


4.18 Palpitations and Somatization

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PROTOCOL 4.21 Palpitations


4.19 Palliative Care for Patients with Heart Failure

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chapter 5Cardiac Surgery Screening, Referral, Anticoagulation, and Postoperative Management

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5.1 History of Cardiac Surgery in Rwanda

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3%

43%54%

Congenital Open rheumatic Other

9

29

132

Visting cardiac surgical teamExternal referralClosed cardiac surgery by local thoracic surgeon


FIGURE 5.1 Indication for Cardiac Surgery between Nov. 2007 and Feb. 2010 (%)

FIGURE 5.2 Source of Cardiac Surgery in Rwanda between Nov. 2007 and Feb. 2010 (n)

chapter!5 | cardiac surgery 109

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?9'[43%"$%7'J1/1C',4$.)9A',4$%#*'`&%#8<4*#'V,,`_X'D&)945'#84'A%&"-'&6'+$%5)$+'*"%A)+$.'#4$:*'*"--&%#)9A';<$95$'#8%&"A8'$99"$.':)**)&9*>//',,`_'-4%6&%:*'3&#8'$5".#'$95'-45)$#%)+'*"%A4%)4*>

S8$)9'&6',&-4'!4.A)":'8$*'$.*&'3%&"A8#'-45)$#%)+')9#4%@49#)&9$.'#4$:*'#&';<$95$>'L.#8&"A8'#84%4')*'9&'+$%5)$+'+$#84#4%)^$#)&9'.$3&%$#&%7')9';<$95$'$#'-%4*49#C'S8$)9'&6',&-4'8$*'3449'$3.4'#&'&-4%$#4'"*)9A'4+8&2

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5.2 Building a National Cardiac Surgery Program

H84%4'$%4'@4%7'64<'9$#)&9$.'+$%5)$+'*"%A)+$.'-%&A%$:*')9'L6%)+$>/Bk/g'H84'+8$..49A4*'&6'4*#$3.)*8)9A'*"+8'+49#4%*'$95'$+8)4@)9A'A&&5'*"%A)+$.'&"#2

/1':)..)&9'&%':&%4'-4&-.4'+$9'4$*).7'D"*#)67'#84'9445'6&%'$#'.4$*#'&94'.&2+$.'+49#4%'#&'-4%6&%:'B11'&%':&%4'*"%A4%)4*'-4%'74$%>'_4'8$@4'4*#):$#45'#8$#'*"+8'+49#4%*'+&".5'-%&@)54'@$.@".$%'%4-.$+4:49#*'6&%'"954%'r0111'-4%'+$*4'V*44'APPENDIX BX>'G%&A%$:*'#8$#'&-4%$#4'&9'B11'&%':&%4'+$*4*'-4%'74$%':"*#'34'$3.4'#&'%4.7'&9'$'*#%&9A'*7*#4:'&6'+8%&9)+'+$%4'+$-$3.4'&6'$9#)+&$A".$#)&9':&9)#&%)9A'$#'5)*#%)+#28&*-)#$.'.4@4.>'H84'6&..&<)9A'


5.2.1 Cardiac Surgical ReferralS$%5)$+'*"%A)+$.'-%&A%$:*'9445'#&'8$@4'$++4**'#&'$'.$%A4'$95'9$#)&9$..7')9+."*)@4'*4#'&6'-&#49#)$.'+$%5)$+'*"%A)+$.'+$95)5$#4*>'b94'+8$..49A4'6&%'+$%5)$+'*"%A)+$.'-%&A%$:*')*'49*"%)9A'#8$#'#84'-&&%'.)@)9A')9'%"%$.'+&:2:"9)#)4*C'.&+$#45'6$%'6%&:'#84'+$-)#$.C'8$@4'4O"$.'$++4**'#&'%464%%$.'6&%'+$%5)$+'*"%A4%7>'H%$5)#)&9$..7')9';<$95$C'$*')9':$97'+&"9#%)4*C'+$%5)$+'*"%A4%7'-%&A%$:*'8$@4'%4.)45'"-&9'$'+&:3)9$#)&9'&6'4E)*#)9A'%464%%$.'*7*#4:*'$95')9#4%:)##49#'+$%5)$+'*"%A)+$.'*+%449)9A'+$:-*>'`$#)&9$.'*+$.42"-'&6'`S('+.)9)+*'$#'5)*#%)+#'8&*-)#$.*'<)..'-.$7'$'+%"+)$.'%&.4')9'4E-$95)9A'$95'49%)+8)9A'#84'-&&.'&6'-&**)3.4'+$%5)$+'*"%A)+$.'+$95)25$#4*'$@$).$3.4'6&%'4@$."$#)&9'37'*-4+)$.)*#*'$#'#84'a9)@4%*)#7'H4$+8)9A'

54*+%)34'8&<'`S('+.)9)+*'6445')9#&'#84'+$%5)$+'*"%A)+$.'*4.4+#)&9'*7*#4:>

b9+4'$'5)*#%)+#'`S('+.)9)+'*7*#4:')*')9'-.$+4C'84$%#'6$)."%4'+$*4*'$%4'CHAPTER 4X>'

$'+$%5)&:7&-$#87'&%'87-4%#49*)@4'84$%#'5)*4$*4C'#84'-$#)49#')*'%464%%45'#&'$'+$%5)&.&A)*#'6&%'+&:-.4#4'4@$."$#)&9'$95'$5@$9+45'4+8&+$%5)&A%$-87>',4$%#'6$)."%4'+.)9)+*'$%4'84.5'&9'#84'*$:4'5$7'4$+8'<44P'$95'-$#)49#*'$%4'5)@)545')9#&'A%&"-*>'H8)*'P)95'&6'&%A$9)^$#)&9'$..&<*'3&#8'+$%5)&.&A)*#*'6%&:'@)*)#)9A'#4$:*'$95'#8&*4'<&%P)9A')9'#84'%464%%$.'+49#4%*'#&'5&'

b9+4'#84'+$%5)&.&A)*#'54#4%:)94*'#8$#'$'-$#)49#')*'$'*")#$3.4'*"%A)+$.'+$95)5$#4C'84'&%'*84'$55*'#84:'#&'$'9$#)&9$.'+$%5)$+'*"%A)+$.'<$)#)9A'.)*#>'G%)&%'#&'4$+8'+$%5)$+'*"%A)+$.':)**)&9C'@)*)#)9A'#4$:*'+$9'%4@)4<'#8)*'.)*#'$*'-$%#'&6'#84)%')9)#)$.'-$#)49#'+$*4'*4.4+#)&9>'

TABLE 5.1'*8&<*'#84'#7-)+$.'4@$."$#)&9*'%4O"4*#45'37'+$%5)$+'*"%A)+$.'#4$:*'-%)&%'#&'*"%A4%7>


TABLE 5.1 Typical Preoperative Evaluation for Cardiac Surgery

History

Physical examination

Laboratory studies

Imaging

5.2.2 Principles of Case Selection?#'8$*'3449'#84'&3*4%@$#)&9'&6'@)*)#)9A'$5".#'+$%5)$+'*"%A)+$.'#4$:*')9';<$95$'#8$#'-$#)49#*'<)#8'%84":$#)+'@$.@".$%'5)*4$*4C'$95'-$%#)+".$%.7'#84'-&&%4*#'$95'#8&*4'6%&:'%"%$.'$%4$*C'-%4*49#'.$#4')9'#84)%'+.)9)+$.'+&"%*4>'!7'#8)*'#):4C'#84*4'-$#)49#*'$%4'$.%4$57'4E-4%)49+)9A'`c,L'S.$**'???'$95'?\'84$%#'6$)."%4'*7:-#&:*C'<)#8')9@&.@4:49#'&6'#<&C'$95'*&:4#):4*'#8%44C'+$%5)$+'@$.@4*>

H8"*C'<8).4')#')*'54*)%$3.4'#8$#'.&+$.'+$%5)$+'*"%A4%7'-%&A%$:*')9'L6%)+$')9)#)$..7'6&+"*'&9'.&<4%2%)*P'*"%A)+$.'+$95)5$#4*C'*7*#4:$#)+$..7'4E+."52)9A'*$.@$A4$3.4'-$#)49#*'<)#8'$5@$9+45'5)*4$*4')*'9&#'$'A&&5'&-#)&9>'H8)*C'$:&9A'9":4%&"*'$55)#)&9$.'6$+#&%*C'<)..'):-$+#'#84'-$+4'<)#8'<8)+8'.&+$.C')954-49549#'+$%5)$+'*"%A4%7'-%&A%$:*'+$9'54@4.&-C'$95'<)..'+&9#)9"4'#&':$95$#4')9@&.@4:49#'&6'@)*)#)9A'-%&A%$:*'#&'-4%6&%:'*"%A4%)4*C'<8).4'#%$)9)9A'.&+$.'-4%*&994.'#&'$**":4'5)%4+#)&9'&6'#84'-%&A%$:*>

?9';<$95$C'+$%5)$+'*"%A)+$.'+$*4'*4.4+#)&9')*'+&&%5)9$#45'9$#)&9$..7'37'#84'+$%5)$+'*"%A4%7'-%&A%$:'5)%4+#&%'<)#8')9-"#'6%&:'$..'+$%5)&.&A)*#*>',4%4'<4'54*+%)34'*&:4'-%)9+)-.4*'&6'+$*4'*4.4+#)&9')9'$'*4##)9A'<84%4'


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[)%*#C'A)@49'@4%7'.):)#45'$++4**'#&'+$%5)$+'*"%A4%7')9';<$95$C'-$#)49#*'"954%'$A4'K1'$%4'-%)&%)#)^45>

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H8)%5C'*&:4'-$#)49#*'<&".5'%4O")%4':".#)-.4'*#$A45'*"%A4%)4*'#&'$+8)4@4'$'6"..'%4-$)%'V4>A>C'+&9A49)#$..7'*)9A.4'@49#%)+.4*X>'H84*4'-$#)49#*'$%4'

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[&"%#8C':&*#'@)*)#)9A'+$%5)$+'*"%A)+$.'#4$:*'5&'9&#'644.'#8$#')#')*'*$64'#&'&-4%$#4'&9':&%4'#8$9'&94'8)A8.7'+&:-.4E'+$*4'-4%'5$7>'\)*)#)9A'#4$:*':"*#'3$.$9+4'#84'*&:4#):4*2+&:-4#)9A'54:$95*'&6'-$#)49#'$+")#7'$95'+&:-.4E)#7'<)#8'#84'%4$.)#)4*'&6'-&*#&-4%$#)@4'+$%4'$@$).$3).)#7>'(4*-)#4'#84*4'%4*&"%+4'.):)#$#)&9*C':&%4'$5".#'-$#)49#*'8$@4'%4+4)@45':".#)-.4C'%$#84%'#8$9'*)9A.4C'@$.@4'-%&+45"%4*'6&%'#84'-$*#'B'74$%*>'b@4%'#84'-$*#'K'74$%*C':".#)-.4'@$.@4'&-4%$#)&9*'8$@4'34+&:4'#84'9&%:'6&%'-$#)49#*'<)#8'%84":$#)+'@$.@".$%'5)*4$*4C')9+."5)9A'*4@4%$.'#%)-.42@$.@4'*"%A4%)4*>

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L*'&6'(4+4:34%'J1/1C'#84%4'<4%4':&%4'#8$9'/11'-$#)49#*'$<$)#)9A''+$%5)$+'*"%A4%7')9';<$95$>

5.3 Common Procedures for Cardiac Valves

`S('9"%*4*'$95'A494%$.)*#'-87*)+)$9*'<&%P)9A'$#'5)*#%)+#'8&*-)#$.*'9445'#&'"954%*#$95'*&:4'&6'#84'3$*)+*'$3&"#'+$%5)$+'@$.@".$%'*"%A4%7>/d'H84'6&..&<2"-')**"4*'6&%'-$#)49#*'6&..&<)9A'+$%5)$+'*"%A4%7'54-495C')9'-$%#C'&9'#84'9$#"%4'&6'#84'*"%A4%7'#847'8$@4'"954%A&94>

H84%4'$%4'#<&'3$*)+'#7-4*'&6'@$.@".$%'*"%A4%)4*W'@$.@4'%4-$)%'$95'@$.@4'%4-.$+4:49#>'R)#%$.'@$.@4*'$95'#%)+"*-)5'@$.@4*'+$9'*&:4#):4*'34'%42-$)%45>'\$.@4'%4-$)%'8$*'#84'$5@$9#$A4'&6'-%4*4%@)9A':&%4'&6'#84'9&%:$.'6"9+#)&9'&6'#84'@$.@4>'b9'#84'&#84%'8$95C'-$#)49#*'<)#8'$'@$.@4'%4-$)%'&6#49'%4O")%4'$'*4+&95'&-4%$#)&9'.$#4%')9'.)64>


L++4**'#&'84$%#'*"%A4%7')9';<$95$'$95'*"%%&"95)9A'+&"9#%)4*')*'.):)#45>'T)@49'#84'6$+#'#8$#'%4&-4%$#)@4'84$%#'*"%A4%7')*'9&#'.)P4.7'#&'34'$'-%)&%)#7')9'#84'94$%'6"#"%4C'4E-4%)49+45'@)*)#)9A'#4$:*'$%4'&-#)9A':&%4'&6#49'6&%'@$.@4'%4-.$+4:49#'#84%$-7'6&%'-$#)49#*'<)#8'%84":$#)+'84$%#'5)*4$*4>

H84'54+)*)&9'&6':4+8$9)+$.'@4%*"*'#)**"4'-%&*#84*4*')*'&6#49'+8$..49A)9AC'$95':"*#')9+&%-&%$#4'3&#8':45)+$.'$*'<4..'$*'+".#"%$.'6$+#&%*>'b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

H84'*4+#)&9*'34.&<'5)*+"**'#84'+&9*)54%$#)&9*')9@&.@45'<)#8'4$+8'#7-4'&6'*"%A4%7>

5.3.1 Mitral or Tricuspid Valve RepairY&:4'@$.@".$%'5$:$A4')*':).5'49&"A8'#&'34'%4-$)%45>'H84':$)9'$5@$9#$A4'

)9#$+#>'H8)*'+&9#%)3"#4*'#&'34##4%'6"9+#)&9'&6'#84'$**&+)$#45'@49#%)+.4>'H84'%)*P'&6'%4&-4%$#)&9'5"4'#&'6$)."%4'&6'#84'%4-$)%'-%&3$3.7'6$..*'*&:4<84%4'34#<449'#84'%)*P*'&6'6$)."%4')9'3)&-%&*#84#)+'$95':4+8$9)+$.'@$.@4*>J1

[&%'-$#)49#*'<)#8':)#%$.'*#49&*)*'5"4'#&'6"*)&9'&6'#84'$9#4%)&%'$95'-&*#42

)*'+$..45'$'5$--2**.#$,$-0'V*44'TABLE 5.2X>'?9'-$#)49#*'<)#8'%4A"%A)#$9#':)#%$.'@$.@4'5)*4$*4C'$':4#$.'%)9A'+$9'34'"*45'#&'*.)A8#.7'9$%%&<'#84'@$.@4>'H84'%)9A')*'-.$+45'$%&"95'#84'&"#4%'45A4'&6'#84'@$.@4'V$.*&'+$..45'#84'$99"."*X>'H8)*'-%&+45"%4')*'+$..45'$'#24>+(44./$1/(*,0>'?9'$55)#)&9C'*&:4'-$#)49#*':$7'$.*&'9445'#&'8$@4'-$%#'&6'#84)%'@$.@4'+"#'$<$7C'&%'

TABLE 5.2 Types of Valve Repairs

Ring annuloplasty Commissurotomy

Indication Mitral or tricuspid regurgitation Mitral or tricuspid stenosis

Anticoagulation Yes, with aspirin Yes, with aspirin


5.3.2 Percutaneous ProceduresL':)9):$..7')9@$*)@4'-%&+45"%4'+$9'&-49'"-'*#49&#)+'@$.@4*'$95'+$9'+.&*4'+4%#$)9'+&9A49)#$.'84$%#'.4*)&9*>'L'*:$..'+$#84#4%')*'-.$+45'#8%&"A8'#84'A%&)9'V)9#&'#84'64:&%$.'$%#4%7'&%'@4)9X'$95')*'-$**45'"-<$%5'#&<$%5'#84'84$%#>'Y:$..'+&%%4+#)@4'54@)+4*'+$9'34'-$**45'#8%&"A8'#84*4'+$#824#4%*'#&'%4-$)%'#84'5464+#>'?6'#8)*'#7-4'&6'-%&+45"%4'+$9'34'5&94C')#')*'-%464%%45C'*)9+4')#'+$%%)4*'#84'*:$..4*#'%)*P>'

;<$95$'+"%%49#.7'5&4*'9&#'8$@4'$'+$%5)$+'+$#84#4%)^$#)&9'.$3&%$#&%7C'3"#')#')*'-&**)3.4'#&'-4%6&%:'*&:4'+&9A49)#$.'-%&+45"%4*'<)#8'4+8&+$%2

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

4$%.7')9'#84'54@4.&-:49#'&6'$'+$%5)$+'*"%A)+$.'-%&A%$:'$%4'V/X'#84'9445'6&%'5)$A9&*#)+'+$#84#4%)^$#)&9C'$95'VJX'54.)@4%7'&6'.&<2%)*P'-%&+45"%4*'6&%'+&9A49)#$.'84$%#'5)*4$*4>

5.3.3 Mechanical Valves

5"%$3.4>'b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

b"#+&:4*')9'A494%$.'6&%'-$#)49#*'<)#8':4+8$9)+$.'@$.@4*'8$@4'3449'-&&%')9'L6%)+$'34+$"*4'&6'<4$P'+8%&9)+'+$%4')96%$*#%"+#"%4>J/'_4'34.)4@4'#8$#'"*4'&6'+&::"9)#7'84$.#8'<&%P4%*'#&'*"--&%#'$584%49+4'<)#8'#84%$-7'+$9'):-%&@4'#84*4'&"#+&:4*'$*'#847'8$@4')9'#84'+$*4'&6',?\'$95'#"34%+".&*)*>

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5.3.4 Bioprosthetic Valves!)&-%&*#84#)+'@$.@4*'$%4':$54'6%&:'.)@)9A'#)**"4'V6%&:'$'+&<C'-)AC'&%'8":$9X'$95'$%4'*8$-45'#&'%4*4:3.4'$'9&%:$.'84$%#'@$.@4>'Y)9+4'#847'$%4':$54'&6'.)@)9A'#)**"4C'#84'%)*P'&6'#8%&:3&*)*')*'A%4$#.7'%45"+45C'$95'&9.7'$*-)%)9'V/11':AC'/Ei5$7X')*'944545>',&<4@4%C'9&%:$.'84$%#'6"9+#)&9'+$9'5$:$A4'#84*4'@$.@4*>'H847'%$%4.7'.$*#':&%4'#8$9'/1'74$%*C'$95'*&:42#):4*':"+8'.4**>JJ'VY44'TABLE 5.3>X

!)&-%&*#84#)+'@$.@4*'$%4'A&&5'6&%'#84'6&..&<)9A'#7-4*'&6'-$#)49#*W

/>' J,<&-2'!*=%#0&+'c&"9A'+8).5%49'$%4'.)P4.7'#&'9445'$'*4+&95'&-4%$#)&9'$#'*&:4'-&)9#'34+$"*4'#847'<)..'&"#A%&<'#84)%'@$.@4h'$':4+8$9)+$.'

%4-$)%'&%'%4-.$+4:49#>

J>'?,;0&2,C2'!*=%BK0"#*&-2"-024!,24"&828,2!"$02'!*=%#0&+'_$%6$%)9'+$"*4*'3)%#8'5464+#*')9'-%4A9$9+7'$95')9+%4$*4*'#84'%)*P'&6':)*+$%%)$A4>'H84%4')*'9&')54$.'*#%$#4A7'6&%':$9$A)9A'<&:49'<8&'$%4'-%4A9$9#'$95'8$@4'$':4+8$9)+$.'@$.@4>JBCJK'[&%'$..'<&:49'&6'+8).5234$%)9A'$A4'<)#8'$':4+8$9)+$.'@$.@4C'+&9#%$+4-#)&9'<)..'34'@4%7'):-&%#$9#>

B>' L"8*0&8128!"82=*$02*&2%*18#*'8124*8!,<82'!#,&*'2'"#02*&C#"18#<'8<#0+'R4+8$9)+$.'@$.@4*'+$9'34'5$9A4%&"*')6'#84%4')*'9&#'$'A&&5'*7*#4:'&6'6&..&<2"-'+.&*4'#&'#84'-$#)49#=*'8&:4>'?9'#8)*'*+49$%)&C'$'3)&-%&*#84#)+'@$.@4':$7'34'$'.4**'%)*P7'&-#)&9>

TABLE 5.3 Types of Replacement Heart Valves

Bioprosthetic Mechanical

Anticoagulation Aspirin Warfarin

Longevity ~10 years, probably less ~20 years, potentially life-long

Endocarditis risk Increased Increased

Used in

future pregnancies desire more children

5.4 Early Post-Operative Evaluation (First 3 Months)

?9'$55)#)&9'#&'#84)%'%4A".$%'@)*)#*'#&'$'+8%&9)+'+$%4'+.)9)+C'-&*#2+$%5)$+'*"%A4%7'-$#)49#*'*8&".5'34'*449'37'$'+$%5)&.&A)*#'$#'.4$*#'K'#):4*')9'#84'

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5.4.1 Heart Failure

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5.4.2 Sternal Wound Infection and DehiscenceH&'$++4**'#84'84$%#'6&%'*"%A4%7C'#84'*#4%9":':"*#'34'+"#>'L#'#84'495'&6'#84'-%&+45"%4C'#84'*#4%9":')*'%4-$)%45'"*)9A'<)%4*>'b9'&++$*)&9C'*&:4'&6'#84*4'<)%4*':$7'*4-$%$#4C'+$"*)9A'548)*+49+4'$95')9*#$3).)#7'&6'#84'*#4%9":>'?6'#8)*'&++"%*C'-$#)49#*'$%4'$#'%)*P'6&%')964+#)&9*'&6'#84'<&"95'$95'&6'#84'544-4%'*#%"+#"%4*'&6'#84'84$%#>'H8)*')*'$9'4:4%A49+7h'-$#)49#*'9445')::45)$#4'#%4$#:49#'<)#8'$9#)3)&#)+*>'L#'4$+8'&6'#84'4$%.7'@)*)#*'


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2+)9')*'$9'$.#4%9$#)@4')9'#8&*4'<)#8'$'-49)+)..)9'$..4%A7W'Z11':A')9'$5".#*C'J1':AiPA')9'+8).5%49'V:$E):":'Z11':AX>

5.4.5 Atrial ArrhythmiasL6#4%'+$%5)$+'*"%A4%7C'-$#)49#*'$%4'$#'8)A8'%)*P'6&%'54@4.&-)9A'$#%)$.'

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5.5 Ongoing Monitoring of the Post-Operative Patient

L6#4%'#84'4$%.7'-&*#2&-4%$#)@4'-4%)&5C':&*#'-$#)49#*'*8&".5'34'$3.4'#&'34'6&..&<45'-%):$%).7'$#'5)*#%)+#'[email protected]')9'`S('+.)9)+*>';464%%$.'#&'$'+$%5)&.&2A)*#'&%'#&'%464%%$.'+49#4%*'*8&".5'34'&9'$9'$*2944545'3$*)*>',&<4@4%C')96&%:$#)&9'$3&"#'#84'-$#)49#*'*8&".5'*#)..'34'+&::"9)+$#45'#&'$'+49#%$.'+&&%5)9$#&%'#&'$)5'<)#8':&9)#&%)9A'$95'4@$."$#)&9'&6'#84'9$#)&9$.'%464%2%$.'*7*#4:>

G$#)49#*'+&9#)9"4'#&'34'$#'%)*P'6&%'+4%#$)9'+&:-.)+$#)&9*>'`S('+.)9)2+)$9*'*8&".5'4@$."$#4'6&%'#84*4'$#'4$+8'6&..&<2"-'@)*)#>'L97'+&:-.)+$2#)&9'*8&".5'34'%4+&%545')9'#84'-$#)49#'+8$%#'$95'+&::"9)+$#45'#&'#84'9$#)&9$.'+$%5)$+'*"%A4%7'+&&%5)9$#&%>'

5.5.1 Fever in Patients with Prosthetic Heart ValvesG$#)49#*'<)#8'$97'#7-4'&6'-%&*#84#)+'84$%#'@$.@4'%4:$)9'$#'%)*P'6&%'@$.@4')964+#)&9*'V495&+$%5)#)*X>'H84'-$#)49#=*'#4:-4%$#"%4'*8&".5'34'+84+P45'$#'4$+8'6&..&<2"-'@)*)#'$95'#84'-$#)49#'*8&".5'34'$*P45'$3&"#'*"3D4+#)@4'

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+$"*4'&6'-%&*#84#)+'@$.@4'495&+$%5)#)*')9';<$95$>'L9'4:4%A49+7'*#&+P'&6'@$9+&:7+)9'*8&".5'34':$54'$@$).$3.4'#&'$..'5)*#%)+#'8&*-)#$.*'#8$#'$%4'6&..&<)9A'-$#)49#*'$6#4%'@$.@".$%'84$%#'*"%A4%7>

*4-*)*'V#$+87+$%5)$C'.$3&%45'3%4$#8)9AXC'&%'$'94<':"%:"%C'#84'-$#)49#'*8&".5'34')::45)$#4.7'#%$9*64%%45'#&'#84')9-$#)49#'5)*#%)+#'8&*-)#$.'<$%5>'H<&'*4#*'&6'3.&&5'*8&".5'34'5%$<9'6&%'+".#"%4*'V4$+8'6%&:'$'*4-$%$#4')9#%$@49&"*'-"9+#"%4X>'!.&&5'+".#"%4*'$%4'A494%$..7'-&*)#)@4')9'+$*4*'&6'495&+$%5)#)*'$95'$%4'4**49#)$.'6&%'#84'+8&)+4'&6'.&9A2#4%:'$9#)3)&#)+*>'!.&&5')*'*49#'#&'#84'%464%%$.'+49#4%'.$3')9'#84'+$-)#$.C'*)9+4'5)*#%)+#'8&*-)#$.*'$%4'+"%%49#.7'"9$3.4'#&'-%&+4**'3.&&5'+".#"%4*>

-4%)-84%$.'@$*&-%4**&%*'*"+8'$*'5&-$:)94')6'944545X'$95'#849'#%$9*264%%45'#&'#84'+$-)#$.'6&%'%464%%$.'+49#4%k.4@4.'+$%4>'Y"+8'#%$9*64%*'*8&".5'34'+&::"9)+$#45'-%&:-#.7'#&'#84'9$#)&9$.'+$%5)$+'*"%A4%7'+&&%5)9$#&%'$95'#&'#84'+$%5)&.&A)*#'6&..&<)9A'#84'-$#)49#>'

L6#4%'3.&&5'+".#"%4*'$%4'5%$<9C'4:-)%)+'$9#)3)&#)+*'*8&".5'34'*#$%#45>'?9#%$@49&"*'@$9+&:7+)9')*'#84'-%464%%45'4:-)%)+'#%4$#:49#C'3"#')6'#8)*'5%"A')*'9&#'$@$).$3.4C'#849'#84'+&:3)9$#)&9'&6'+.&E$+)..)9'$95'+46#%)$E&94')*'$9'$.#4%9$#)@4'V*44'TABLE 5.4X>


TABLE 5.4 Empiric Antibiotic Treatments for Endocarditis

Antibiotic Indication Adult dose Pediatrics dose E"ect on warfarin

Vancomycin Empiric endocarditis therapy, methicillin-resistant Staphylococcus aureus, Staphylococcus epidermidis, enterococcus

1 gm 2x/d 10 mg/kg 4x/d No e#ect

OR (Combination therapy with cloxacillin + ceftriaxone or penicillin G)

Cloxacillin Empiric endocarditis therapy, methicillin-sensitive Staphylococcus aureus, empiric treatment of cellulitis in patients with prosthetic heart valves

2 gm daily IV 50 mg/kg every 6 hours IV

No e#ect

Ceftriaxone Empiric endocarditis therapy, Streptococcus viridans, empiric treatment of urinary tract infection, pneumonia in patients with prosthetic heart valve

2 gm daily IV or IM

100 mg/kg/d IV or IM (maximum 2 gm)

Decreases warfarin e#ect

Penicillin G Empiric endocarditis therapy, Streptococcus viridans

4.5 million units IV 4x/d

50,000 U/kg IV 4x/d

No e#ect

G$#)49#*'<8&'8$@4'$'64@4%'3"#'9&94'&6'#84'&#84%'<$%9)9A'*)A9*'+$9'34'4@$."$#45'6&%'&#84%'+&::&9')964+#)&9*C'*"+8'$*':$.$%)$C'"%)9$%7'#%$+#')964+#)&9*C'-94":&9)$C'&%'+4..".)#)*>'!.&&5'+".#"%4*'*8&".5'34'5%$<9'$95'*49#'#&'#84'%464%%$.'8&*-)#$.'346&%4'*#$%#)9A'4:-)%)+'$9#)3)&#)+*>'G$#)49#*'*8&".5'34'8&*-)#$.)^45'<8).4'$<$)#)9A'3.&&5'+".#"%4'%4*".#*>'?6'#84%4')*'9&'):-%&@4:49#')9'$'-$#)49#=*'*#$#"*'<)#8)9'JK'8&"%*C'#%$9*64%'#&'#84'%464%%$.'+49#4%'*8&".5'34'$%%$9A45>'VY44'PROTOCOL 5.1>X

Patient with prosthetic

valve and fever (T ≥ 38° C or

100.4° F)

1. Heart failureOR

2. BP ≤ 80/40 mmHgOR

3. Other signs of sepsis or endocarditis

(e.g., new murmur)

1. History and physical examinationFollowed by laboratory evaluation as needed:1. Urinalysis2. Peripheral blood smear for malaria3. Chest x-ray

Clear source of fever?

Improvement within 48 hours

1. Hospitalize at district level2. Treat infection empirically

Continue management with careful attention to:1. Warfarin management (if relevant)2. In-hospital risks such as IV-line

and urinary catheter infections3. Venous thromboembolism

No fever within 14 days from admission

Weekly follow-up at NCD clinic for

1 month

1. Hospitalize at district hospital2. Stabilize blood pressure with fluids3. Draw two sets of blood cultures4. Start empiric antibiotics for endocarditis (Table 5.4)5. Transfer as quickly as possible to referral hospital for admission, blood culture, echocardiography, and specific antibiotic therapy

YES

NO

YES

NO

NO

YES NO

YES


PROTOCOL 5.1 Management of Fever in Patients with Prosthetic Heart Valves

_4'5&'9&#'$55%4**'#84'.&9A2#4%:'#%4$#:49#'&6'495&+$%5)#)*')9'#8)*'A")54>'b94':$D&%')**"4')9'#84'#%4$#:49#'&6'-%&*#84#)+2@$.@4'495&+$%5)#)*')*'#8$#')#'"*"$..7')9@&.@4*')9#%$@49&"*'$9#)3)&#)+*'6&%'$#'.4$*#'Z'<44P*'V*44'TABLE 5.5X>'b%$.'$9#)3)&#)+*'$.&94'$%4'9&#'$9'$++4-#$3.4'$.#4%9$#)@4'#&')9#%$@429&"*'#%4$#:49#C'$95'#84'9445'#&'6%4O"49#.7'+8$9A4'-4%)-84%$.')9#%$@429&"*'+$#84#4%*'+$9'34'$'-%&3.4:>'U66&%#*'*8&".5'34':$54'#&')9#%&5"+4'*P)..*')9':)5.)94')9#%$@49&"*'+$#84#4%'-.$+4:49#'$95'+$%4'$#'#84'5)*#%)+#'8&*-)#$.'.4@4.>

L9'$55)#)&9$.'+&9*)54%$#)&9')*'#8$#':$97'$9#)3)&#)+*':&5)67'#84'4664+#'&6'<$%6$%)9'V*44'TABLE 5.6X>'?9'-$#)49#*'#$P)9A'<$%6$%)9C'#84')9#4%9$#)&9$.'


9&%:$.)^45'%$#)&'V?`;X'*8&".5'$.*&'34'6&..&<45'+.&*4.7'5"%)9A'$9#)3)&#)+'#%4$#:49#>

[)9$..7C'=,(1&0/$5$55.*+(.#'.*'495&+$%5)#)*')*'-$%#)+".$%.7'$AA%4**)@4')9'-%&*#84#)+'84$%#'@$.@4*'$95':$7'4@49'%4O")%4'%4&-4%$#)&9>'L..'495&+$%25)#)*'+$*4*'*8&".5'34':$9$A45'@4%7'+.&*4.7'<)#8'#84'5)%4+#&%'&6'#84'9$2#)&9$.'+$%5)$+'*"%A)+$.'-%&A%$:')9'5)*+"**)&9'<)#8'#84'9$#)&9$.'+$%5)$+'*"%A)+$.'+&::"9)#7>

TABLE 5.5 Some Organism-Specific Treatments for Prosthetic Valve Endocarditis

Antibiotic Duration of therapy Adult dose Pediatrics dose E"ect on warfarin

Staphylococcus aureus (methicillin-resistant): combination therapy

Vancomycin 6 weeks 1 gm 2x/d 10 mg/kg 4x/d No e#ect

Gentamycin 2 weeks 3 mg/kg/d IV or IM divided into 3 doses

50 mg/kg every 6 hours IV

No e#ect

Rifampin 6 weeks 300 mg orally daily 7 mg/kg orally 3x/d Markedly decreases warfarin e#ect

Staphylococcus aureus (methicillin-sensitive): combination therapy

Cloxacillin 6 weeks 2 gm daily IV 50 mg/kg every 6 hours IV

No e#ect

Gentamycin 2 weeks 3 mg/kg/day IV or IM divided into 3 doses

50 mg/kg every 6 hours IV

No e#ect

Rifampin 6 weeks 300 mg orally daily 7 mg/kg orally 3x/d Markedly decreases warfarin e#ect

Streptococcus viridans (ceftriaxone or penicillin G)

Ceftriaxone 6 weeks 2 grams daily IV or IM 100 mg/kg/d IV or IM (maximum 2 gm)

Decreases warfarin e#ect

Penicillin G 6 weeks 4.5 million units IV 4x/d

50,000 U/kg IV 4x/d No e#ect

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5.6 Penicillin Prophylaxis for Patients with Surgically Corrected Rheumatic Valvular Disease

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5.7 Methods of Anticoagulation and Indications

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,&<4@4%C'-$#)49#*'$#'8)A84%'%)*P'&6'*#%&P4C'*"+8'$*'#8&*4'<)#8'$'P9&<9'#8%&:3"*'&%'$':4+8$9)+$.'84$%#'@$.@4C'%4O")%4'$'A%4$#4%'54A%44'&6'


$9#)+&$A".$#)&9>'H8)*')*'$+8)4@45'<)#8'<$%6$%)9C'<8)+8')98)3)#*'*79#84*)*'&6'*4@4%$.'3.&&5'+&$A".$#)&9'-%&#4)9*>'_$%6$%)9')*'$'#%)+P7'5%"A>'R4#$3&2.)*:'@$%)4*'A%4$#.7'6%&:'-4%*&9'#&'-4%*&9'$95'<)#8)9'#84'*$:4'-$#)49#'6%&:'5$7'#&'5$7C'$95'4@49'8&"%'#&'8&"%C'54-495)9A'&9')9#4%$+#)&9*'<)#8'6&&5'$95':45)+$#)&9*>'TABLE 5.6'.)*#*'*&:4'&6'#84'+&::&9':45)+$#)&9*'#8$#')9#4%$+#'<)#8'<$%6$%)9>

TABLE 5.6 Common Drug Interactions with Warfarin

Drug E"ect on INR

Co-trimoxazole Increase

Metronidazole Increase

Ciprofloxacin Increase

Cimetidine Increase

Rifampin Decrease

Antiretroviral drugs Increase or decrease

Alcohol Increase or decrease

R&%4&@4%C'<$%6$%)9'#$P4*'*4@4%$.'5$7*'#&'$+8)4@4'$'#84%$-4"#)+'.4@4.'&6'$9#)+&$A".$#)&9>'Y"3+"#$94&"*'49&E$-$%)9'VS.4E$94X'&%'*"3+"#$94&"*'"96%$+#)&9$#45'84-$%)9')*'"*45')9'-$#)49#*'$#'$'@4%7'8)A8'%)*P'&6'*#%&P4'<8&'%4O")%4'$55)#)&9$.'$9#)+&$A".$#)&9'V$'N3%)5A4QX'"9#).'#84'<$%6$%)9'#$P4*'4664+#>

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S&::&9')95)+$#)&9*'6&%'$9#)+&$A".$#)&9')9'&"%'+.)9)+*'$95'5)*#%)+#'8&*-)22

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TABLE 5.7 Anticoagulation Agents and Indications

Indications Warfarin or aspirin? Heparin bridge?

Goal INR Duration of therapy

Heart failure and atrial fibrillation

Peripartum cardiomyopathy Aspirin N/A N/A Lifelong

Mitral stenosis in sinus rhythm Aspirin N/A N/A Lifelong

Mitral stenosis with signs of prior stroke Warfarin No 2.0–2.5 Lifelong

Atrial fibrillation (without heart failure) Aspirin N/A N/A Lifelong

Atrial fibrillation (with heart failure) Warfarin No 2.0–2.5 Lifelong

Prosthetic valves

Bioprosthetic tricuspid valve Warfarin for the first 3 months, then aspirin

Yes 2.5–3.0 Lifelong

Other bioprosthetic valves (not tricuspid) Aspirin N/A N/A Lifelong

Mechanical aortic valve Warfarin Yes 2.5–3.0 Lifelong

Mechanical mitral valve Warfarin Yes 3.0–3.5 Lifelong

Mechanical tricuspid valve Warfarin Yes 3.0–3.5 Lifelong

Thrombus

Ventricular thrombosis Warfarin Yes 2.0–2.5 6 months

Deep-vein thrombosis Warfarin Yes 2.0–2.5 3 months

Pulmonary embolism Warfarin Yes 2.0-2.5 6 months

5.8 Initiating Warfarin Therapy

G%&#&+&.*')9'-%4@)&"*'+8$-#4%*'8$@4')95)+$#45'<849'$9#)+&$A".$#)&9'

5.8.1 Contraindications to Warfarin Therapy!46&%4'*#$%#)9A'<$%6$%)9'#84%$-7C'-$#)49#*'*8&".5'34'$**4**45'6&%'%4.$2#)@4'+&9#%$)95)+$#)&9*'#&'<$%6$%)9'#84%$-7>

_$%6$%)9')9'-%4A9$9+7'+$9'+$"*4'*4%)&"*'3)%#8'5464+#*'$*'<4..'$*'64#$.'

<)#8'#84'<&:$9>'?9'*&:4'+$*4*C'*"+8'$*'#84'-%4*49+4'&6'$':4+8$9)+$.'@$.@4C'#84'%)*P'#&'#84':&#84%'&6'9&#'#$P)9A'<$%6$%)9'<)..'.)P4.7'&"#<4)A8'

&6'$9'4:3&.)+'4@49#':$7'34'544:45'.&<'49&"A8'#8$#'#84'<&:$9'<)..'+8&&*4'9&#'#&'#$P4'<$%6$%)9'5"%)9A'#84'-%4A9$9+7>


;4+49#C'*4%)&"*'3.445)9A')*'$9&#84%'%4.$#)@4'+&9#%$)95)+$#)&9>'LA$)9C'#8)*'*8&".5'34'<4)A845'$A$)9*#'#84'%)*P'&6'4:3&.)+'4@49#*')9'54+)5)9A'<84#84%'&%'9&#'#&'*#$%#'<$%6$%)9>

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5.8.2 Monitoring Warfarin?9':$97'.&<2)9+&:4'*4##)9A*C'#84'+&*#*'&6'<$%6$%)9'$95'&6':&9)#&%)9A'54@)+4*'$%4'*449'$*'$9')9*"%:&"9#$3.4'3$%%)4%'#&'$9#)+&$A".$#)&9>'?9'&"%'4E-4%)49+4C')9@4*#:49#')9'#8)*')9#4%@49#)&9')*'+&*#24664+#)@4'$95'.4**'5$9A4%&"*'#8$9'A494%$..7'-4%+4)@45>'G$#)49#*'$%4'"*"$..7'@4%7'@)A).$9#'$3&"#'+84+P)9A'#84)%'&<9'?`;>'G%&-4%.7'#%$)945'+&::"9)#7'84$.#8'<&%P4%*'$%4'$'A%4$#'$)5')9'84.-)9A'#&':&9)#&%'$95'#)#%$#4'<$%6$%)9'5&*4*>'

6&%'#84)%'%)*P'&6'*#%&P4'&%'&#84%'4:3&.)+'4@49#*>'G$#)49#*'$#'.&<'%)*P'&6'

8$@4'<$%6$%)9')9)#)$#45')9'#84'&"#-$#)49#'*4##)9A'<)#8'+.&*4'6&..&<2"->

TABLE 5.8'.)*#*'%4+&::49545'5&*)9A'6&%'&"#-$#)49#')9)#)$#)&9'&6'<$%6$%)9>'`&#4'#8$#'#8)*'5&*)9A')*'.&<4%'#8$9'#7-)+$..7'"*45')9'*4##)9A*'<)#8':&%4')9#49*)@4':&9)#&%)9A>

TABLE 5.8 Initial Outpatient Warfarin Dosing

Patient age Initial dose

Adults 2.5 mg/day

Children (5–40 kg) 1 mg/day

G$#)49#*'$#'8)A8'%)*P'&6'4:3&.)+'4@49#*')9+."54'#8&*4'<)#8':4+8$9)+$.'@$.@4*'$95'#8&*4'<)#8'$9'$+#)@4'+.&#')9'#84'84$%#'&%'#84'544-'@4)9*'&6'#84'.4A*>'L97'-$#)49#'<8&')*'$#'@4%7'8)A8'%)*P'&6'#8%&:3&*)*'$95'<8&'#84%46&%4'%4O")%4*'$'84-$%)9'3%)5A4':"*#'34'*#$%#45'&9'<$%6$%)9')9'#84'8&*-)#$.>'a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

2.5 mg/day

YESPatient with

indication forwarfarin

Requires heparinbridge because high risk

of embolic events?(Table 5.9)

Patientpregnant?

NO

Start warfarin therapy:Adults: 2.5 mg/day

Chidren 5–40 kg: 1 mg/day

If INR ≥ goal INR do not start warfarinIf INR ≤ goal INR, start warfarin at half

normal dose (Table 5.10)

Reconsider indications forwarfarin. Consider aspirin

as an alternativeYES

Palpable liver on exam or known

liver failure?

Check INR prior to initiating

warfarin therapyElevated

INR?

Assign community health worker

Follow-up in one weekat the district hospital

NO

NO YES

YES

1. Admit to district hospital2. Start warfarin (Table 5.8)3. Start a medication to bridge

the patient (Table 5.9)


?6'#84'<$%6$%)9')*'5)*+&9#)9"45'$95'#84%$-7'8$*'#&'34'%42)9)#)$#45'5"4'#&'$9'?`;'34.&<'/>0C')#')*'34*#'#&'8&*-)#$.)^4'#84'-$#)49#'$95'$5:)9)*#4%'$9&#84%'$A49#'"9#).'#84'?`;'%)*4*'8)A84%'#8$9'J>1>

PROTOCOL 5.2 Initiating Warfarin Therapy

TABLE 5.9 Therapies For Bridging Anticoagulation

Medication Dosing

Enoxaparin (Clexane) 1 mg/kg twice per day

Heparin (subcutaneous)27,28 Adult: 15,000 units 2x/dChild: 250 units/kg 2x/d

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5.9 Titrating Warfarin Therapy

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TABLE 5.10 General Principles of Warfarin Titration

INR Action

Greater than 5.0 or complaints of bleeding Hospitalize for warfarin adjustment

Above goal (INR elevated by more than 2.0) Stop warfarin for 2 daysDecrease warfarin dose by 1 mg

Above goal (INR elevated by less than 2.0) Evaluate for changes in medications or dietDecrease warfarin dose by 0.5–1 mg

At goal Continue current warfarin dose

Below goal Evaluate for changes in medications or dietAssess for nonadherenceIncrease warfarin dose by 0.5–1 mg

Below 1.5 If at high risk of embolic events, hospitalize for war-farin adjustment and possibly subcutaneous heparin or subcutaneous enoxaparin (Clexane) therapyAssess for nonadherence and discuss with the patient’s community health worker

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PROTOCOL 5.3'&"#.)94*'#84'*#4-*')9@&.@45')9'$5D"*#)9A'<$%6$%)9'5&*)9A')9'$..'-$#)49#*'&9'$9#)+&$A".$#)&9>'

NO

NO

YES

YES YES

NO

YES

YES

NO

NO

YES

NO

YES

YES YES

NO

NO

NO

YES

YES

NO

YES

Patient onwarfarin INR ≥ 5

INR ≥ 1above goal,

but ≤ 5

INR previouslyat goal

for ≥ 1 month1. Recheck INR in 2 weeks

INR at goalOR

≤ 1 abovegoal

INR lowerthan goal but

≥ 1.5

INR ≤ 1.5

Patienttaking

warfain?

Patienttaking

warfain?

Currentlyhospitalizedfor low INR

Currentlyhospitalized for

high INR

Reason forhigh INR identifiedand resolved (e.g.,overdose, acute

illness)

Currentlyhospitalizedfor high INR

1. Hold warfarin2. Admit to district hospital3. Consider reasons for high INR and address4. Recheck INR in 2 days

1. Continue warfarin2. Observe for 1 day, recheck INR3. If INR still near goal, discharge4. Recheck INR in one week

1. Restart warfarin at previous dose2. Observe for 1 day, recheck INR3. If INR still near goal, discharge4. Recheck INR in one week

1. Address reason for non-adherence2. Restart warfarin at previous dose3. Recheck INR in 1 week

1. Hospitalize2. Start enoxaprin OR, if enoxaparin

not available start heparin SC (Table 5.9)

1. Restart warfarin at lower dose (10%–20% lower than original dose)2. Observe for 1 day, recheck INR3. If INR still near goal, discharge4. Recheck INR in one week

1. Address reason for non-adherence2. Restart warfarin at previous dose3. Recheck INR in 3 days

1. Continue to hold warfarin2. Recheck INR in 2 days

1. Decrease warfarin by 10%–20%2. Recheck INR in 3 days

1. Increase warfarin by 10%–20%2. Recheck INR in 1 week

1. Increase warfarin by 10%–20%2. Recheck INR in 3 days


PROTOCOL 5.3 Titrating Warfarin Therapy

5.10 Drug Supply and Patient Monitoring

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5.11 Dangers of Anticoagulation

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http://salamcentre.emergency.it/

http://www.wspcca.org.za/

http://www.saveachildsheart.org/

http://rwanda.ooh.org.au/

http://www.teamheart.org

http://www.healingheartsnorthwest.com/

http://www.chaine-espoir.be/


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chapter 6Chronic Kidney Disease

6.1 Etiology of Chronic Kidney Disease in Rural Rwanda

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TABLE 6.1 Causes of End-Stage Renal Disease in Sub-Saharan Africa and the U.S.

Glomerulonephritis or unknown

Hypertension Diabetes Other

Average (Nigeria and Senegal)1

54% 27.4% 11.9% 6.7%

USA3 15.4% 24.2% 37.3% 22.9%


6.2 Screening for Renal Failure in High-Risk Populations

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chapter!6 | chronic kidney disease 137

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TABLE 6.2 Relationship between Urine Dipstick and 24-hour Urine Protein Results

Urine dipstick result 24-hour urine protein

Top-normal Trace 150 mg

Microalbuminuria 1+ 200–500 mg

Proteinuria 2+ 0.5–1.5 gm

Nephrotic-range 3+ 2–5 gm

Nephrotic-range 4+ 7 gm

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http://www.metrohealthresearch.org/schelling

http://www.metrohealthresearch.org/schelling


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6.3 Classification of Renal Failure

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http://www.nephron.com/cgi-bin/CGSIdefault.cgi

http://www.nephron.com/cgi-bin/CGSIdefault.cgi

http://www.kidney.org/professionals/kdoqi/gfr_calculator.cfm

http://www.kidney.org/professionals/kdoqi/gfr_calculator.cfm

http://www.kidney.org/professionals/kdoqi/gfr_calculatorPed.cfm

http://www.kidney.org/professionals/kdoqi/gfr_calculatorPed.cfm

YES

YES

YES

NO

NO

YES

NO

NO

YES

CKD 1 or 2(nl GFR, 2+

proteinuria, noinfection)

Referred to NCDclinic for suspectedor confirmed CKD

Check blood pressure, urine dipstick, HIV andelectrolyte panel including

creatinine, glucose, and hemoglobin

HIV

Consider early ARV initiation

ANY?1. Signs of urinary

obstruction (difficulty urinatingand abdominal pain or distention)?

2. Potassium ≥ 6.5 mEq/L?3. Di!culty breathing?

Refer to district hospitalfor admission

Obtain random urine proteinto creatinine ratio

≥ 3+ proteinuria ratio ≥ 3

1. Obtain serum albumin2. If CKD 1-3, start low-dose

ACE inhibitor unless contraindications (see Table 8.5)

3. Refer for evaluation for nephrotic syndrome by a nephrologist, internist, or pediatrician

1. If patients already followed in continuity clinic, (e.g., for HTN, DM or HIV) continue management in that clinic (at health- center level)

2. Start ACE inhibitor unless contraindication (see Table 8.5)3. Blood pressure goal ≤ 120/80 mmHg (see Table 8.5)4. Avoid NSAIDs, other nephrotoxins5. Return to NCD clinic once per year to check creatinine


TABLE 6.3 Stages of Chronic Kidney Disease

Degree of dysfunction Glomerular filtration rate

CKD 1 and 2 Proteinuria alone 60 ml/min/1.73m2

CKD 3 Moderate dysfunction 30–59 ml/min/1.73m2

CKD 4 and 5 Severe dysfunction 29 ml/min/1.73m2

6.4 Initial Evaluation and Management of Chronic Kidney Disease (CKD)

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PROTOCOL 6.1 Initial Evaluation of Chronic Kidney Disease Stage 1 or 2


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'$*'84$%#'6$)."%4X>

NO

YES

YES YES

YES

YES

NO

YES

NO

CKD 3(GFR 30–59)

Check blood pressure, urinedipstick, HIV and electrolyte

panel including creatinine andglucose and hemoglobin

Return in NCD clinic in 3-6 months to

recheck creatinine

HIV, DM, or heartfailure?

Control of underlying

disease process (e.g., glucose

control, ARVs)

CKD 4 or 5(GFR ≤ 29)

Assess and address symptoms

(see Protocol 6.3)

Fill out intake form for edematous conditions, including screening questions

for heart failure, TB, and a basic echocardiogram, and kidney ultrasound

CKD 3, 4, or 5(GFR ≤ 59)

Potentially reversible?Meets all criteria:1. No heart failure

2. No ultrasound signs of irreversiblekidney disease (see Table 6.3)

Refer to a nephrologist,internist, or pediatrician for

evaluation and possiblespecific therapy

Option for renal transplant?

Refer to a nephrologist, internist, or pediatrician

for evaluation and possible

specifictherapy

1. Start ACE unless contraindication

2. Start FeSO4 200 mg 3x/day x 30 days if Hb ≤ 10 g/dL

3. Goal BP ≤ 130/80 mmHg (see Table 8.5)

1. Control BP(goal ≤ 130/80)

2. Consider furosemide

3. Avoid ACEinhibitors(see Table 8.6)

Referred to NCDclinic for suspectedor confirmed CKD

ANY?1. Signs of urinary

obstruction (difficulty urinatingand abdominal pain or distention)?

2. Potassium ≥ 6.5 mEq/L?3. Di!culty breathing?

Refer to district hospitalfor admission


PROTOCOL 6.2 Initial Evaluation of Chronic Kidney Disease Stage 3, 4, and 5

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FIGURE 6.1 Normal Kidney Anatomy on Ultrasound (Arrowheads show the medullary pyramids, and star shows the outer cortex)


FIGURE 6.2 Ultrasound in Chronic Kidney Disease: Loss of Di"erentiation between Cortex and Medulla

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TABLE 6.4 Ultrasound Findings Specific for Severe, Irreversible Kidney Disease

1. Echogenic cortex (more than liver), plus a combined length 20 cm

2. Very small kidneys with a combined length less than 16 cm

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FIGURE 6.3 Hydronephrosis on Ultrasound

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YES YES

NO

NO

YES

YES

NO

K 5–6 mEq/LStop these medicationsand return to NCD clinic

in two weeks

TakingACE inhibitors,

spironolactone or K supplement?

Estimated GFR ≤ 59

(CKD 3, 4, or 5)

Repeat K test

False positivedue to

hemolysisContinue usual follow-up

1. Start or increase furosemide dose (starting dose 20 mg orally 1 time per day) unless contraindication

2. Return to NCD clinic in two weeks


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6.5 Hyperkalemia

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PROTOCOL 6.3 Outpatient Management of Mild Hyperkalemia


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6.6 Palliative Care for Chronic Kidney Disease

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TABLE 6.5 Common Physical Symptoms in Advanced Chronic Kidney Disease and Their Treatment18

Physical symptom Cause Treatment (see Chapter 2 for details)

Fatigue and drowsiness86%

Depression Assess for depression and treat if found.

Fluid overload Diurese for fluid overload, if needed.

Anemia, poor nutrition, other organ failure, uremia, insomnia

Itch84%

Dry skin Emollients for dry skin.

Secondary hyperparathyroidismHyperphosphatemiaAnemiaOpioids

Antihistamine such as diphenhydramine (can worsen fatigue and delirium).Steroid.

Dyspnea (the most distressing symptom)80%

Pulmonary edemaPleural e#usionMetabolic acidosisAnemiaAspirationComorbid CHF, COPD, or other lung pathology

If comfort and quality of life are the only goals of care, not preservation of renal function, diurese for symptomatic pulmonary or peripheral edema.Opioid relieves dyspnea of any cause. Renal dosing for morphine (see APPENDIX A).

Delirium (agitated or hypoactive)76%

Metabolic derangementsHypoxia/hypercapniaMedications

Reduce or eliminate culprit medications, if possible.Haloperidol.

Pain73%

Bone pain due to 2̊ hyperparathyroidismDiabetic neuropathyPolycystic kidney diseaseCalciphylaxis (hemodialysis patients only)

Avoid NSAIDS due to nephrotoxicity and increased risk of bleeding with uremic platelet dysfunction.Paracetamol is safe and requires no dose adjustment for renal failure.Morphine: active metabolite accumulates in CKD 5 and can cause neurotoxicity. Use lower dose and/or longer dosing interval than usual.

Anorexia71%

Nausea (see below)Diabetic gastroparesisDry mouth

Anti-emetics (see below).Metoclopramide for gastroparesis.Oral care.Steroid to stimulate appetite.

Swelling in legs/arms71%

Fluid overloadLow oncotic pressure due to proteinuria and malnutritionComorbid heart failure

Elevate edematous extremities. Elastic wraps as tolerated.If comfort and quality of life are the only goals of care, not preservation of renal function, diurese for symptomatic peripheral edema or anasarca.

Dry mouth69%

Intravascular volume depletion (can exist even with total body fluid overload).

Instruct family caregivers to keep mouth moist with sips of liquid or sponge.


Physical symptom Cause Treatment (see Chapter 2 for details)

Constipation65%

Medications including opioids and anticholinergicsIntravascular volume depletion

Laxative

Nausea with or without vomiting59%

UremiaEmetogenic medicationsDiabetic gastroparesis

Reduce or eliminate culprit medications, if possible.Haloperidol for nausea due to endogenous or exog-enous emetogenic toxin. Start with low dose.Metoclopramide for gastroparesis.

Cough47%

Pulmonary edemaAspirationComorbid COPD or other lung pathology

If comfort and quality of life are the only goals of care, not preservation of renal function, diurese for symptomatic pulmonary edema.Opioid relieves cough of any cause. Renal dosing for morphine.

TABLE 6.6 Common Psychological Symptoms in Advanced Chronic Kidney Disease and Their Treatment

Psychological symptom Treatment

Anxiety78%

Psychosocial supportsHaloperidolDiazepam (can cause delirium and paradoxical agitation)

Feeling sad65%

Psychosocial supports

DepressionUnknown prevalence

Psychosocial supportsAntidepressant such as fluoxetine or amitriptyline

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6.7 Renal Replacement Therapy (Hemodialysis and Peritoneal Dialysis)

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6.8 Renal Transplantation

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6.9 Acute Kidney Failure in Hospitalized Patients

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chapter 7Diabetes

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chapter!7 | diabetes 155

7.1 Opportunistic Identification and Screening for Diabetes in Acute Care Health Center Clinics

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TABLE 7.1 Diabetes Diagnosis: Blood Sugar Measurement and Symptoms

Blood sugar 126 mg/dL (7 mmol/L) fastingOR

200 mg/dL (11 mmol/L) random with symptomsOR

200 mg/dL (11 mmol/L) with an oral glucose tolerance test

Glycosylated hemoglobin (HbA1c) 6.5% (using a point-of-care device)

Symptoms of chronic hyperglycemia Polyuria (excessive urination)Polydipsia (excessive thirst)Weight loss

Imm

edia

tely

tran

sfer

toho

spita

l

Cons

ider

oth

erca

uses

of t

hepa

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’s sy

mpt

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and

tran

sfer

toho

spita

l

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cau

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f sym

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logi

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Bloo

d su

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≥ 15

0 m

g/dL

(8.3

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)

Age

≤ 18

Li

kely

type

1 di

abet

es m

ellit

us,

refe

r to

dist

rict h

ospi

tal f

or in

patie

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ofdi

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initi

atio

n of

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lin th

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y

Pres

ent t

o ac

ute

care

cl

inic

with

any

of t

he

follo

win

g sy

mpt

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1. D

ehyd

ratio

n2.

Fre

quen

t urin

atio

n3.

Thi

rst

4. In

crea

sed

appe

tite

5. W

eigh

t los

s or g

ain

Bloo

d su

gar

200-

400

mg/

dL(1

1–22

mm

ol/L

)?

Any

war

ning

sign

s:1.

Slo

w, d

eep

brea

thin

g 2.

“Fru

ity” b

reat

h3.

Abd

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ain,

nau

sea,

vom

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4. S

leep

y, n

ot re

spon

ding

5. B

lood

pre

ssur

e ≤

90/

60 m

mH

g

Like

ly ty

pe 2

or m

ixed

dia

bete

s mel

litus

, ref

er

to d

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t NCD

clin

ic fo

r con

firm

atio

n of

di

agno

sis a

nd in

itiat

ion

of o

ral h

ypog

lyce

mic

s (P

roto

col 7

.2)

Bloo

d su

gar

≥ 40

0 m

g/dL

(22

mm

ol/L

)?

YES

NO

YES

NO

YES

YES

NO

NO

NO

YES

NO

YES

1. A

dults

: giv

e 50

0 m

l nor

mal

salin

e (N

S)

bolu

s, th

en c

ontin

ue N

S at

250

cc/

hour

. Ch

ildre

n ≤

12 y

ears

old

: giv

e 20

ml/

kg N

S bo

lus,

then

con

tinue

at m

aint

enan

ce d

ose

2. G

ive

0.2

U/k

g (o

r 10

units

for a

n ad

ult)

SC

of re

gula

r ins

ulin

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heck

blo

od su

gar e

very

hou

r and

giv

e ad

ditio

nal i

nsul

in u

ntil

tran

sfer

(Tab

le 7

.3)


PROTOCOL 7.1 Diagnosis of Diabetes and Management of Hyperglycemia at Health-Center Level


7.2 Recognition and Treatment of Emergency States (Hyperglycemia and Hypoglycemia)

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TABLE 7.2 Danger Signs in Hyperglycemia

Early findings Notes

Signs of dehydration Dry mucus membranes, skin tenting, decreased urine output

Hypotension From loss of fluids

Slow, deep breathing From ketosis

Abdominal pain, nausea and vomiting

Fruity breath Ketones have a fruity odor

Late findings (neurological) Notes

Focal motor deficits

Altered mental status Agitation, sleepiness, eventually coma

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TABLE 7.3 Insulin Therapy of Patients with Hyperglycemia ( 250 mg/dL) and Danger Signs Awaiting Transfer

Blood sugar Regular insulin dose (given subcutaneously)

For children ( 40 kg) For adults

Initial bolus 0.2 units/kg x 1 10 units

Recheck blood glucose every hour

250 mg/dL (13 mmol/L) 0. 1 unit/kg/hour 5 units/hour

150–250 mg/dL (8–13 mmol/L) 0.05 unit/kg/hour 2.5 units/hour

150 mg/dL ( !8 mmol/L) Stop insulin, continue normal saline or lactated ringers

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TABLE 7.4 Diagnosis and Treatment of Hypoglycemia

Symptoms Somnolence or agitationConfusionLethargyDizziness, nauseaSeizuresStroke-like symptomsSweatingTremorsPalpitations, anxiety

Causes Correctable:Overdose of medication (insulin or orals)Increased exerciseSkipped meals

Not (easily) correctable:Reduced renal function (diminished clearance of hypoglycemic agents)Liver failure (inability to produce glycogen to correct serum hypoglycemia)

Treatment Juice, soft drink, sugar water (if able to follow commands)In adults IV glucose 50% solution (if unable to follow commands)In children 12 give glucose 50% solution by nasogastric tube (if unable to follow commands)3–12 hours of frequent finger-stick checks

7.3 Principles and Initial Management of Diabetes

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TABLE 7.5 Glucose Control Goals

Reasonable control More intensive control

Pre-meal and pre-bedtime glucose

150–180 mg/dL(8.3–10 mmol/L)

120–150 mg/dL (6.7–8.3 mmol/L)

Hemoglobin A1c 7.5%–8%: average blood glucose of170–185 mg/dL (9.4–10.5 mmol/L)

7.0%–7.5%: average blood glucose of154–170 mg/dL (8.6–9.4 mmol/L)

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PROTOCOL 7.2 Treatment of Diabetes with Oral Hypoglycemic Agents (in Adults)


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TABLE 7.6 Oral Hypoglycemic Therapy

Steps Metformin Glibenclamide

7 a.m. 7 p.m. 7 a.m. 7 p.m.

1 500 mg - 5 mg -

2 500 mg 500 mg 5 mg 5 mg

3 1000 mg 500 mg 10 mg 5 mg

4 1000 mg 1000 mg 10 mg 10 mg

5 Add glibenclamide Add metformin

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TABLE 7.7 Common Causes for Hyperglycemia in Patients on Insulin

Problems with insulin injection and mixing technique

Problems with insulin storage or expiration

Unusual dietary excess

Active infection (e.g., malaria, urinary, skin, or pulmonary)

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A."+&*4'$95'*8&".5'34'%4+&::49545'#&'$..'-$#)49#*C')%%4*-4+#)@4'&6'<4)A8#>',&<4@4%C')9+%4$*4*')9'4E4%+)*4'+$9'%4*".#')9'87-&A.7+4:)$')6')9*".)9'&%'A.)349+.$:)54'$%4'34)9A'$5:)9)*#4%45>'G$#)49#*'*8&".5'34':$54'$<$%4'&6'#8)*')**"4C'$95'-%$+#)#)&94%*'*8&".5'P44-'#8)*'%)*P')9':)95'<849'$5D"*#)9A'5%"A'%4A):49*>'_8494@4%'$@$).$3.4C'+&::"9)#7'84$.#8'<&%P4%*'*8&".5'34'"*45'#&'):-%&@4'#84%$-4"#)+'$584%49+4'$95'#&'-%&@)54'*&+)$.'*"--&%#>

7.4 Management of Diabetes with Insulin Therapy

R$97'-$#)49#*'<)#8'5)$34#4*o)9'&"%'+&8&%#C'$--%&E):$#4.7'8$.6'&6'-$2#)49#*o9445')9*".)9'#84%$-7>K]'TABLE 7.8'.)*#*'#84')95)+$#)&9*'6&%')9*".)9>'Y"++4**6".')9)#)$#)&9'&6')9*".)9'#84%$-7'%4O")%4*'4E#49*)@4'-$#)49#'+&"92*4.)9A'V*44'SECTION 7.3.2X>'_4'%464%'$..'-$#)49#*')9'9445'&6')9*".)9'#&'#84'5)*#%)+#'8&*-)#$.'6&%'$5:)**)&9>'H84':$)9'A&$.*'&6'8&*-)#$.)^$#)&9'$%4'-$2#)49#'45"+$#)&9'$95'$.*&'#%4$#:49#'$95'-%4@49#)&9'&6'5$9A4%&"*'.4@4.*'&6'87-4%A.7+4:)$>'_4'5&'9&#'$##4:-#'#&'4*#$3.)*8'#)A8#'+&9#%&.'&6'3.&&5'A."+&*4>'?9*".)9'%4O")%4:49#*')9'#84'8&*-)#$.':$7'5)664%'*"3*#$9#)$..7'6%&:'#8&*4')9'#84'+&::"9)#7>'[&&5'-%&@)*)&9')928&*-)#$.')*'@$%)$3.4>'Y&:4'8&*-)#$.*')9';<$95$'-%&@)54':4$.*'#&'-$#)49#*C'3"#':&*#'5&'9&#>'H84%46&%4C'-$#)49#*':$7'34'%4+4)@)9A':&%4'&%'.4**'6&&5'#8$9'#847'<&".5'$#'8&:4>'b6#49'.4@4.*'&6'-87*)+$.'$+#)@)#7'$%4'$.*&'$.#4%45')9'#84'8&*-)#$.'*4##)9A>'L*'$'%4*".#'&6'#84*4'@$%)$3.4*C')#')*'*$64%'#&'5)*+8$%A4'-$#)49#*'&9'#84':)9):":'$:&"9#'&6')9*".)9'94+4**$%7'#&'-%4@49#'.)642#8%4$#49)9A'87-4%A.7+4:)$'$95'#)#%$#4'#84)%'5&*4'$6#4%<$%5>'H&'#8)*'495C'$..'-$#)49#*'*8&".5'34'$**)A945'$'+&::"9)#7'84$.#8'<&%P4%'VS,_X'-%)&%'#&'5)*2+8$%A4>'H84'S,_'<)..'-4%6&%:'5$).7'8&:4'@)*)#*'#&'84.-'<)#8')9*".)9'$5:)9)*#%$#)&9'$95'5&+":49#$#)&9'&6'A."+&*4'.4@4.*>'`S('+.)9)+)$9*'#849'%4@)4<'#8)*')96&%:$#)&9'$#'<44P.7'5)*#%)+#'`S('+.)9)+'@)*)#*'$95':$P4''$5D"*#:49#*'$++&%5)9A.7>'H8)*'-%&+4**'+&9#)9"4*'"9#).'$'*#$3.4')9*".)9'


%4A):49')*'4*#$3.)*845C'"*"$..7'<)#8)9'*4@4%$.'<44P*>'PROTOCOL 7.3'&"#2.)94*'#84'*#4-*'#$P49')9')9)#)$#)&9'$95'$5D"*#:49#'&6')9*".)9'#84%$-7>

TABLE 7.8 Indications for Insulin Therapy

Type 1 diabetes

Failed maximum oral therapy

Pregnancy

Creatinine greater than 150 mmol/L (1.6 mg/dL) (which prevents use of metformin),and unable to control glucose with glibenclamide alone

History of diabetic ketoacidosis

Child 18 years of age

Firs

t visi

t fo

r ins

ulin

Refe

r to

hosp

ital

for

adm

issio

n

Cont

inue

cur

rent

di

abet

es m

edic

atio

ns.

Follo

w-u

p 4–

8 w

eeks

Glu

cose

cont

rol a

t goa

l?

(see

Tab

le 7

.5)

Iden

tify

insu

lin

regi

men

(sta

rted

as i

npat

ient

)

Follo

w-u

p 2–

4 w

eeks

Ensu

re a

cces

s to

regu

lar m

eals

/sna

cks.

Nut

ition

al su

ppor

t as n

eede

d.

Hyp

ogly

cem

ia?

NO

YES

YES

NO

NO

YES

YES

YES

NO

NO

Trea

t inf

ectio

n, O

R ch

ange

insu

lin b

atch

, O

R en

sure

goo

d in

sulin

stor

age

and

inje

ctio

n te

chni

ques

.

NO

YES

Dia

bete

s mel

litus

AN

DA

lread

y on

insu

linO

RH

as n

ew in

dica

tion

for i

nsul

in th

erap

y(s

ee T

able

7.8

)

1. A

ny W

arni

ng S

igns

(see

Tab

le 7

.2)

AN

D

gluc

ose ≥

200

mg/

dl (1

1 mm

ol/L

)O

R2.

Glu

cose

≥ 4

00 m

g/dl

(22.

2 m

mol

/L)

1. A

dults

: giv

e 50

0 m

l nor

mal

salin

e (N

S) b

olus

, the

n co

ntin

ue N

S at

250

cc/

hour

. Chi

ldre

n ≤

12 y

ears

old

: giv

e 20

ml/

kg N

S bo

lus,

then

con

tinue

at m

aint

enan

ce d

ose

2. G

ive

0.2

U/k

g (o

r 10

units

for a

n ad

ult)

SC

of

regu

lar i

nsul

in if

glu

cose

≥ 2

50 m

g/dL

(13

mm

ol/L

)3.

Che

ck b

lood

suga

r eve

ry 1–

4 ho

urs a

nd g

ive

ad

ditio

nal i

nsul

in u

ntil

tran

sfer

(see

Tab

le 7

.3)

Corr

ecta

ble

caus

e of

hype

rgly

cem

ia?

(see

Tab

le 7

.7)

Incr

ease

insu

lin(s

ee T

able

7.10

)

Dec

reas

e in

sulin

(see

Tab

le 7

.10)

Corr

ecta

ble

caus

e of

hypo

glyc

emia

?(s

ee T

able

7.4

)

If on

ora

l med

icat

ions

:1.

Sto

p gl

iben

clam

ide

2. C

ontin

ue m

etfo

rmin


PROTOCOL 7.3 Initiation and Adjustment of Insulin Regimens


7.4.1 Initiation of Insulin Therapyb9+4'#84'54+)*)&9'#&'*#$%#')9*".)9'8$*'3449':$54C'-$#)49#*'*8&".5'34'%464%%45'#&'#84'5)*#%)+#'8&*-)#$.'6&%'$5:)**)&9>'?9'#84'8&*-)#$.C'#84'6&..&<2)9A'*#4-*'<)..'34'#$P49W

O!"&-02*&2,#"=2;0%*'"8*,&2#0-*;0&2*C2"=#0"%M2,&2;"V*;<;2%,10+

Q8,)2-=*K0&'=";*%0+'Y)9+4'A.)349+.$:)54'*#):".$#4*')9*".)9'*4+%4#)&9'37'#84'-$9+%4$*C')#*'+&9#)9"45'"*4')9'#84'*4##)9A'&6')9*".)9'#84%$-7'+$9')9+%4$*4'#84'%)*P'&6'87-&A.7+4:)$>'[&%'#8)*'%4$*&9C'A.)349+.$:)54'*8&".5'34'5)*+&9#)9"45')9'$..'-$#)49#*'&9')9*".)9>

'R4#6&%:)9'*8&".5'34'+&9#)9"45')9'-$#)49#*'<8&'$%4'34A)929)9A')9*".)9'#84%$-7>'R4#6&%:)9'+$"*4*'#84'3&57=*'#)**"4*'#&'34##4%'%4*-&95'#&')9*".)9C'%4*".#)9A')9'54+%4$*45'84-$#)+'A."+&*4'&"#-"#>'R4#6&%:)9':$7'.&<4%')9*".)9'5&*4'%4O")%4:49#*>

Q8"#82*&1<=*&+'?9'#84'8&*-)#$.C'-$#)49#*'<)..'34'*#$%#45'&9'$9')9*".)9'%4A):49'#8$#')*'$--%&-%)$#4'6&%'#84:'V*44'SECTION 7.4.2X>

L#,$*%02)"8*0&820%<'"8*,&+'_8).4'8&*-)#$.)^45C'-$#)49#*'*8&".5'34'A)@49'45"+$#)&9'%4A$%5)9A'#84'$--%&-%)$#4')9D4+#)&9'&6')9*".)9'$95'#84'):-&%#$9+4'&6'%4A".$%':4$.*>

W&1<#02-,,%2,<8)"8*0&82C,==,4B<)2)="&+'L#'5)*+8$%A4C'$'+&::"9)#7'84$.#8'<&%P4%'*8&".5'34'$**)A945'#&'#84'-$#)49#>'H8)*'+&::"9)#7'

<44P*C'+84+P'$95'%4+&%5'5$).7'3.&&5'A."+&*4'.4@4.*>'H84'-$#)49#'*8&".5'$.*&'34'A)@49'$9'$--&)9#:49#'6&%'&94'<44P'$6#4%'5)*+8$%A4'#&'34'4E$:)945'$#'#84'5)*#%)+#2.4@4.'`S('+.)9)+>'H84'):-&%#$9+4'&6'6&..&<2"-'*8&".5'34'4:-8$*)^45'#&'#84'-$#)49#>

7.4.2 Insulin Regimen Selection?9*".)9'*8&".5'34':$54'$@$).$3.4'$#'#84'84$.#82+49#4%'[email protected]'$.&9A'<)#8'$--%&-%)$#4'#%$)9)9A')9')#*'"*4>'[&%'$'-%&A%$:'#8$#')*'%4.$#)@4.7'94<')9'$'5)*#%)+#C')#':$7'34'-%464%$3.4'#&':$9$A4')9*".)9254-49549#'-$#)49#*'<)#8'5)$34#4*'$#'#84'5)*#%)+#'[email protected]'<84%4'9"%*4'+.)9)+)$9*'8$@4':&%4'4E#49*)@4'#%$)9)9A'$95'-87*)+)$9*'$%4'$@$).$3.4'#&'*"-4%@)*4>',&<4@4%C')9':&*#'+$*4*C'-$#)49#*'.)@4'6"%#84%'6%&:'#84'5)*#%)+#'+.)9)+*'#8$9'6%&:'84$.#82+49#4%'+.)9)+*>'?9'*"+8'*)#"$#)&9*C'$'+&::"9)#7'84$.#8'<&%P4%')*'@)#$.'#&'49*"%)9A'#8$#'-$#)49#*'5&'9&#'%"9'&"#'&6')9*".)9>'H84'+&::"9)#7'84$.#8'<&%P4%'&%'

-&**)3.4'#&'54+49#%$.)^4')9*".)9':$9$A4:49#'#&'#84'84$.#82+49#4%'+.)9)+C'&9+4'$'-$#)49#'8$*'4*#$3.)*845'$'*#$3.4'%4A):49>

?9';<$95$C'#84%4'$%4'#8%44'#7-4*'&6')9*".)9'$@$).$3.4'#8%&"A8'-"3.)+'-8$%:$+)4*'V*44'TABLE 7.9XW'`G,'V24*./(,(#)'&%'/'4,'XC'%4A".$%'V24*./24'+


#(12)'XC'$95'+&:3)9$#)&9'V-26,''&%'-26,(#)X>'`G,')*'A494%$..7'+&9*)54%45'#&'34'$'3$*$.')9*".)9h')#'-%&@)54*'$'.&9A2$+#)9A'3$*4.)94')9*".)9'.4@4.>'b9'#84'&#84%'8$95C'%4A".$%')9*".)9')*'*8&%#4%2$+#)9AC'$95')*'#8"*'"*"$..7'"*45'#&'#%4$#':4$.#):4'A."+&*4'*"%A4*>'S&:3)9$#)&9')9*".)9')*'$'#8)%5'&-#)&9C'<8)+8'+&9*)*#*'&6'$'-%4:$54':)E#"%4'&6'%4A".$%'$95'`G,')9*".)9>'H84':&*#'+&::&9'%$#)&'6&%'-%42:)E45')9*".)9')*']1iB1'V]1m'`G,C'B1m'%4A".$%X>

TABLE 7.9 Properties of Insulin Available in Rwanda

Regular (rapide) NPH (insulatard or lente) Combination (70/30 or mixte)

Time to onset 20–30 minutes 1–2 hours 30 minutes

Peak e#ect 2.5–5 hours 4–12 hours 3–8 hours

Duration 4–12 hours 18–24 hours 18–24 hours

Dosing 20–30 minutes before meals

Once or twice daily, around 7 am and 7 pm (or bedtime)

20–30 minutes before breakfast and/or dinner

Vial appearance (manufacturer-specific)

Clear Cloudy Cloudy

H84'$@$).$3.4'#7-4*'&6')9*".)9'+$9'34'"*45')9')*&.$#)&9'&%')9'@$%)&"*'+&:23)9$#)&9*'#&'$+8)4@4'#84'54*)%45'4664+#>'Y):-.4%'%4A):49*'%4*".#')9'.&&*4%'A."+&*4'+&9#%&.'#8$9'#84'+&:-.4E'%4A):49*>'b6'+&"%*4C':&%4'+&:-.4E'

-$#)49#*'"*)9A')9*".)9'*8&".5'8$@4'$++4**'#&'%4A".$%'$**)*#$9+4'6%&:'$'#%$)945'+&::"9)#7'84$.#8'<&%P4%>'

H84')9)#)$.'%4A):49'<)..'34'54#4%:)945')9'#84')9-$#)49#'*4##)9AC'3"#')#':$7'9445'#&'34'$5D"*#45'$6#4%'#84'-$#)49#')*'5)*+8$%A45>'H84'*):-.4*#')9*".)9'%4A):49')*'$'*)9A.4'9)A8##):4')9D4+#)&9'&6'`G,>'H8)*'$--%&$+8'#$%A4#*'#84'6$*#)9A'3.&&5'*"A$%'$95'+$9'*4%@4'$*'$'3").5)9A'3.&+P'6&%'6"#"%4'$5D"*#:49#*C')6'944545>

H8)*'*#%$#4A7'8$*'3449'*8&<9'#&'+&9#%&.'A."+&*4')9'%&"A8.7'8$.6'&6'-$#)49#*'<)#8'5)$34#4*')9'$'a>Y>'-&-".$#)&9>Kg',&<4@4%C')9'&"%'4E-4%)49+4C':&*#'-$#)49#*')9'%"%$.';<$95$'+$99&#'34'+&9#%&..45'&9'$'&9+42$25$7'%4A):49>'H8)*':$7'34'34+$"*4'#84)%')9*".)9'*4+%4#)&9')*':&%4'):-$)%45'#8$9')9'#84'$@4%$A4'-$#)49#'<)#8'#7-4'J'5)$34#4*')9'$9')95"*#%)$.)^45'*4##)9A>'R&*#'&6'&"%'-$#)49#*'%4O")%4'#<)+425$).7'`G,'<)#8'%4A".$%')9*".)9'&%'#<)+4'5$).7'-%42:)E45')9*".)9>'H84*4'%4A):49*'$@&)5'*4@4%4'87-4%A.7+4:)$'5"4'#&'+$%3&875%$#42%)+8':4$.*>'TABLE 7.10'&"#.)94*'#84'$@$).$3.4')9*".)9'%4A):49*')9'&%54%C'6%&:'*):-.4*#'#&':&*#'+&:-.4E>'H84':&*#'+&::&9.7'"*45'%4A):49*')9';<$95$'$%4'8)A8.)A8#45')9'%45>


TABLE 7.10 Insulin RegimensRe

gim

enIn

ject

ions

Cove

rage

of

bas

al

glyc

emia

Cove

rage

at

mea

lsN

otes

Star

ting

dose

type

1St

artin

g do

se ty

pe 2

NPH

(ins

ulat

ard

or le

nte)

1x/d

ay1

Som

eN

one

Mos

t sim

ple,

but

not

goo

d co

vera

ge

if hi

gh-c

arbo

hydr

ate

diet

Not

app

ropr

iate

0.2

units

/kg/

day

or

10 u

nits

/day

(whi

chev

er is

le

ss) g

iven

at b

edtim

e

NPH

(ins

ulat

ard

or le

nte)

2x/

day

2G

ood

Non

eG

ood

for s

ome

patie

nts w

ith ty

pe

2 di

abet

es, b

ut a

gain

pro

blem

with

co

vera

ge if

hig

h-ca

rboh

ydra

te d

iet

Not

app

ropr

iate

0.3–

0.6

units

/kg/

day:

60%

pre

-bre

akfa

st,

40%

pre

-din

ner

(20–

30 m

inut

es b

efor

e m

eal)

70/3

0 (m

ixte)

2x

/day

2

Goo

dBr

eakf

ast a

nd

dinn

er (n

o lu

nch

cove

rage

)

Post

-pra

ndia

l hyp

ergl

ycem

ia. F

or

high

-car

bohy

drat

e di

ets,

may

nee

d cl

oser

to a

50/

50 m

ix

Not

app

ropr

iate

0.3–

0.6

units

/kg/

day:

50

% p

re-b

reak

fast

, 50

% p

re-d

inne

r(2

0–30

min

utes

bef

ore

mea

l)

NPH

(ins

ulat

ard

or le

nte)

and

re

gula

r (ra

pide

) In

sulin

2x/

day

2G

ood

Brea

kfas

t and

di

nner

Lunc

h m

ay

be c

over

ed b

y m

orni

ng N

PH

Allo

ws p

atie

nts t

o co

ntro

l mix

Patie

nts c

ombi

ne in

sulin

from

two

vial

s (N

PH a

nd re

gula

r) a

nd g

ive

th

e in

ject

ion

2x/d

ay

0.2–

0.3

units

/kg

0.5–

0.7

units

/kg

Giv

e 50

% o

f dos

e as

NPH

60%

pre

-bre

akfa

st40

% p

re-d

inne

rG

ive

50%

of d

ose

as re

gula

r(s

plit

even

ly p

re-b

reak

fast

and

pre

-din

ner,

20

–30

min

utes

bef

ore

mea

l)

Basa

l/Pr

andi

al3

Goo

dA

ll m

eals

Best

for l

arge

mid

day

mea

ls D

inne

r-tim

e N

PH a

nd re

gula

r co

mbi

natio

n. R

egul

ar a

lone

with

br

eakf

ast a

nd lu

nch

0.2–

0.3

units

/kg

0.5–

0.7

units

/kg

Giv

e 50

% o

f dos

e as

NPH

One

dos

e pr

e-di

nner

com

bine

d w

ith d

inne

r-tim

e re

gula

r in

sulin

Giv

e 50

% o

f dos

e as

regu

lar

(spl

it ev

enly

and

giv

en 2

0-30

min

utes

prio

r to

mea

ls)


7.5 Insulin Use in the Community

R&1<=*&2*&X0'8*,&+2H7-)+$..7C')9*".)9')9D4+#)&9*'*8&".5'34'A)@49')9'#84'*"3+"#$94&"*'6$#'&6'#84'$35&:49>'L.#4%9$#)@4'*)#4*')9+."54'#84'*"3+"#$294&"*'6$#'&6'#84'#8)A8*'$95'$%:*>'H84'$35&:)9$.'6$#')*'A494%$..7'#8&"A8#'#&'34'#84'34*#'*)#4'6&%'$3*&%-#)&9'34+$"*4')#'+&9#$)9*'$'A%4$#4%'6$#2#&2:"*+.4'%$#)&>',&<4@4%C'<)#8'%4-4$#45')9D4+#)&9*C':$97'-$#)49#*'54@4.&-'-$)9C'+$.."*4*C'&%'3%")*)9AC'$95'*&:4#):4*'#847'-%464%'$.#4%9$#)9A'*)#4*>'[&%'#8)*'%4$*&9C')#':$7'34'%4$*&9$3.4'#&'%4+&::495'#8$#':&%9)9A')9D4+2#)&9*'34'A)@49'$#'$35&:)9$.'*)#4*C'$95'4@49)9A')9D4+#)&9*')9'#84'#8)A8>'H84'4:-8$*)*'*8&".5'6&+"*'&9'#84'+&9*)*#49#'"*4'&6'#84'*)#4'&%'*)#4*C')9'&%54%'#&'49*"%4'%4.)$3.4'$3*&%-#)&9>

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TABLE 7.11 Example of Glucose Monitoring Chart

Dat

eBe

fore

bre

akfa

stSy

mpt

oms

of

hype

rgly

cem

ia/

hypo

glyc

emia

Befo

re lu

nch

Sym

ptom

s of

hy

perg

lyce

mia

/ hy

pogl

ycem

ia

Befo

re d

inne

rSy

mpt

oms

of

hype

rgly

cem

ia/

hypo

glyc

emia

Befo

re b

edtim

e

Bloo

d su

gar

Insu

linBl

ood

suga

rIn

sulin

Bloo

d su

gar

Insu

linBl

ood

suga

rIn

sulin

Day

1

183

mg/

dL2U

Reg

ular

Non

e2U

Reg

ular

Non

e12

5 m

g/dL

7U N

PH

2U R

egul

arN

one

Day

2

2U R

egul

arN

one

240

mg/

dL2U

Reg

ular

Non

e7U

NPH

2U

Reg

ular

Non

e72

mg/

dL

Day

3

170

mg/

dL2U

Reg

ular

Non

e2U

Reg

ular

Non

e15

0 m

g/dL

7U N

PH

2U R

egul

arN

one

Day

4

2U R

egul

arN

one

204

mg/

dL2U

Reg

ular

Non

e7U

NPH

2U

Reg

ular

Non

e57

mg/

dL


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TABLE 7.12 Principles for Adjusting Insulin 70/30 (Mixte) or 2x/day NPH Regimens

Timing of hyperglycemia/ hypoglycemia

Hyperglycemia(documented)

Hypoglycemia(documented OR symptoms)

Morning/overnight Increase dinner-time or evening insulin by 2 units

Decrease dinner-time or evening basal insulin by 4 units or 10%, whichever is greater

Mid-day/evening Increase morning insulin by 2 units Decrease morning insulin by 4 units or 10%, whichever is greater

TABLE 7.13 Principles for Adjusting Combined Basal (NPH) and Prandial (Regular Insulin) Regimens

Hyperglycemia(documented)

Hypoglycemia(documented OR symptoms)

Middle of the night n/a Decrease PM Regular 2–4 U

Before breakfast Increase PM NPH 2 U Decrease PM NPH 2–4 U

Mid-day Increase AM Regular 2 U Decrease AM Regular 2–4 U

Before dinner Increase AM NPH 2 U Decrease AM NPH 2–4 U

Before bedtime Increase Pre-dinner Regular 2 U

Decrease Pre-Dinner Regular 2–4 U

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TABLE 7.14 Example of Transitioning from 70/30 (Insuline Mixtard) to NPH/Regular (Insuline Lente + Rapide)

Initial dose: Pre-breakfast Pre-dinner

70/30 (Insuline mixtard) 20 units 10 units

Final dose: Pre-breakfast Pre-dinner

NPH (Insuline lente) 14 units (70% of 20 units) 7 units (70% of 10 units)

Regular (Insulin rapide) 6 units (30% of 20 units) 3 units (30% of 10 units)

7.6 Adjuvant Therapies and Routine Monitoring for Complications in Patients with Diabetes

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TABLE 7.15 Common Complications of Diabetes and Their Prevalence in Some African Cohorts

Prevalence52-54 Mode of evaluation Frequency of evaluation

Action if abnormal

Peripheral neuropathy

35%–70% Monofilament sensory testing of the feet. If a microfila-ment is not available, proprioception can be tested. Patients may also complain of neuropathic pain (burning, electrical sensations) in the feet

Once yearly Intensify treatment regimen if possible. Consider treating neuropathic pain with amitriptyline 25 to 100 mg per day orally. Shoes if needed. Counsel on foot protection

Foot ulcer 1.7%–10% Visual inspection, probe evaluation to rule out osteomyelitis

n/a Referral to district hospital for possible debridement and broad-spectrum antibiotics

Retinopathy or sight-threatening eye disease

5%–35% Fundoscopic evaluation or retinal photography

Once every 3 years, performed at a district hospital with an ophthalmic clinical o$cer. More frequent follow-up if established retinopathy.

Intensify treatment regimen if possible. Referral for evalua-tion at an ophthalmic center if needed for intervention

Cataracts 8.7%–25% Fundoscopic evaluation

Once every 3 years performed at a district hospital with an ophthalmic clinical o$cer

Referral for evaluation at an ophthalmic center for intervention

Albuminuria 18% Urine dipstick Every six months Intensify treatment regimen if possible. Add an ACE inhibitor (e.g., lisinopril, 5 mg per day orally)

Nephropathy 19%–34% Serum creatinine testing

Yearly Intensify treatment regimen if possible. Add an ACE inhibitor if no counterindica-tion (e.g., lisinopril, 5 mg per day orally)

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7.7 Diabetes and Pregnancy

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7.8 Social Assistance and Community Health Workers

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chapter 8Hypertension

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$3*&."#4'%)*P'6&%'$'+&:3)9$#)&9'&6'+$%5)&@$*+".$%'4@49#*>ZC]'L*'<4'8$@4'5)*+"**45C':&*#'-4&-.4'<)#8'8)A8'3.&&5'-%4**"%4')9'%"%$.'*"32Y$8$%$9'*4##)9A*'8$@4'9&'%)*P'6$+#&%*'6&%'+$%5)&@$*+".$%'5)*4$*4'347&95'#84)%'87-4%#49*)&9>'R&*#'$3*&."#4'%)*P':&54.*'<&".5'+$.+".$#4'#84'%)*P'&6'$'+$%5)&@$*+".$%'4@49#'6&%'*"+8'-4&-.4'$#'.4**'#8$9'/1m'&@4%'$'0274$%'-42%)&5'4@49'$#'@4%7'8)A8'3.&&5'-%4**"%4*>',&<4@4%C')#')*'"9+.4$%'8&<'<4..'#84*4':&54.*'-%45)+#'#84'&"#+&:4*'$**&+)$#45'<)#8')*&.$#45'87-4%#492*)&9'$#'.4@4.*'$3&@4'/Z1id0'::,AC'-$%#)+".$%.7')9'*"32Y$8$%$9'L6%)+$>'?9#4%9$#)&9$.'87-4%#49*)&9'A")54.)94*'#8$#'4:3%$+4'#84'$3*&."#4'%)*P'$--%&$+84*'8$@4':$54'#84'+$@4$#'#8$#'-$#)49#*'<)#8'-4%*)*#49#'3.&&5'-%4**"%4*'$3&@4'/]1i/11'::,A'V`4<'q4$.$95X'&%'/Z1id0'::,A'V_,bX'*8&".5'%4+4)@4'-8$%:$+&.&A)+'#%4$#:49#'%4A$%5.4**'&6'#84)%'+$.+".$#45'%)*P>gCd'L9&#84%'6$+#&%'9&#'&6#49')9+."545')9'*#$95$%5'#%4$#2:49#':&54.*')*'#84'+&*#'#&'#84'-$#)49#>'[$+).)#723$*45'+8%&9)+'+$%4'6&%'87-4%#49*)&9')*'4E-49*)@4'6&%'-$#)49#*C'4*-4+)$..7')9'%"%$.'$%4$*>'H847':"*#'-$7'6&%'#%$9*-&%#'#&'#84'+.)9)+'$95'$.*&C')9':&*#'84$.#8'*7*#4:*C'6&%'#84'+&*#*'&6'#84)%'+$%4>'b"%'-%&#&+&.*'&664%'&94'$##4:-#'#&'3$.$9+4'#84'

#%4$#:49#'#&'-$#)49#*'$95'*&+)4#7>'H8)*'$--%&$+8'#%4$#*'$..'-$#)49#*'<)#8'

.&<4%'.4@4.*'&6'3.&&5'-%4**"%4'$%4'#%4$#45'&9.7')6'#847'$.*&'8$@4'5)$34#4*C'%49$.'6$)."%4C'&%':&%4'#8$9'#<&'&#84%'+$%5)&@$*+".$%'%)*P'6$+#&%*C'*"+8'$*'$5@$9+45'$A4'VA%4$#4%'#8$9'Z0XC'+"%%49#'#&3$++&'"*4C'&%'&34*)#7>'T)@49'#84'%4.$#)@4.7'.&<'%)*P'&6'54@4.&-)9A'4952&%A$9'5$:$A4'6%&:':).5C'.&94'87-4%#49*)&9'$95'#84'.$%A4'84$.#8'+$%4'$95'5)%4+#'-$#)49#'+&*#*'&6'+8%&92)+':45)+$.'#84%$-7C'<4'8$@4'$5&-#45'$'-&.)+7'&6'<$#+86".'<$)#)9A'6&%'#8)*'A%&"-'&6'-$#)49#*>'_4'34.)4@4'%45"+)9A'#84'6$+).)#723$*45'+&:-&949#'&6'+$%4'6&%'.&<4%2%)*P'87-4%#49*)&9'&664%*'&94'<$7'&6'%45"+)9A'+&*#*'$95':$P)9A'#8)*')9#4%@49#)&9':&%4'$++4**)3.4>'_4'8$@4'9&#'74#'4E-.&%45'$9')9#4%@49#)&9'6&%'.&<2%)*P'87-4%#49*)&9'$#'#84'+&::"9)#7'.4@4.')9'%"%$.';<$95$>'H84'%4$*&9'6&%'#8)*')*'34+$"*4'+&::"9)#7'84$.#8'<&%P4%*'$%4'+"%%49#.7'3"%54945'<)#8'$'8&*#'&6'5)664%49#'#$*P*C'$95'34+$"*4'#84'*8&%#2#4%:'%)*P*'6&%'#84*4'-$#)49#*'$%4'-%&3$3.7'*:$..>'

-$#)49#'8&:4*'$.*&'%45"+4*'84$.#8'*7*#4:'$95'&"#2&62-&+P4#'+&*#*>'R&*#'87-4%#49*)&9')*'%4.$#)@4.7'*):-.4'#&'5)$A9&*4'$95'#%4$#'&9+4'$'*7*#4:''&6'+8%&9)+'+$%4'8$*'3449'4*#$3.)*845>'?9';<$95$C':&*#'87-4%#49*)&9')*':$9$A45'$#'#84'84$.#82+49#4%'.4@4.>'L#'#8)*'[email protected]'9"%*4*'<)#8'$'3$*)+'.4@4.'&6'#%$)9)9A'#%4$#'*):-.4'`S(*'$*'<4..'$*',?\'$95'H!')9')9#4A%$#45'+8%&9)+'+$%4'+.)9)+*>'H84*4'+.)9)+*'#495'#&'34'+.&*4%'#&'-$#)49#*='8&:4*'$95'+&*#'.4**'#&'%"9'#8$9'#8&*4'$#'5)*#%)+#'.4@4.>'G$#)49#*'<)#8'*4@4%4'.4@4.*'&6'87-4%#49*)&9'$%4'%464%%45'#&'#84'5)*#%)+#'8&*-)#$.'&%'5)*#%)+#2.4@4.'`S('+.)9)+'6&%':&%4'*-4+)$.)^45'#%4$#:49#>

chapter!8 | hypertension 189

?9'*&:4'*4##)9A*C'+&:3)9$#)&9'#$3.4#*'V-&.7-)..*X'+"%%49#.7'"954%'542@4.&-:49#':$7'&664%'$9&#84%':4$9*'&6'%45"+)9A'#%4$#:49#'+&*#*'$95')9+%4$*)9A'+&:-.)$9+4C'-$%#)+".$%.7'$:&9A'-$#)49#*'<8&'8$@4'-%4@)&"*.7'*"664%45'$':7&+$%5)$.')96$%+#)&9>/1'H84*4'+&:3)9$#)&9'#$3.4#*'&6#49':)E'$'87-4%#49*)&9'$A49#'<)#8'&#84%':45)+$#)&9*'*"+8'$*'$*-)%)9'$95',RT2S&L'%45"+#$*4')98)3)#&%*'V*#$#)9*X'#&'%45"+4'#84'%)*P'&6'@$*+".$%'4@49#*'$:&9A'87-4%#49*)@4*>',&<4@4%C'9&92)*+84:)+'4@49#*C'*"+8'$*'84$%#'6$).2"%4C'%49$.'6$)."%4C'$95'84:&%%8$A)+'*#%&P4C'+&9*#)#"#4'#84'-%):$%7'%)*P*'6$+45'37'87-4%#49*)@4'-$#)49#*')9'*4##)9A*'*"+8'$*'%"%$.';<$95$>//'[&%'#8)*'%4$*&9C'<4'5&'9&#'$5@&+$#4'#84'%&"#)94'"*4'&6'#84*4'+&:3)9$#)&9'&%'$5D"@$9#'#84%$-)4*'6&%':&*#'87-4%#49*)@4*')9'&"%'*4##)9A>';$#84%C'<4'%4*4%@4'#84'"*4'&6'$*-)%)9'6&%'87-4%#49*)@4'-$#)49#*'<)#8'5)$34#4*>'S"%2%49#.7C'<4'5&'9&#'%4+&::495'$55)9A'*#$#)9*'#&'#84';<$95$9'6&%:".$%7'6&%'%"%$.'6$+).)#)4*'34+$"*4'&6'#84'.&<')9+)549+4'&6'@$*+".$%'4@49#*>

8.1 Clinic and Community-Based Hypertension Screening

?9'%"%$.';<$95$C'87-4%#49*)&9C',?\C'$95'*#%4-#&+&++$.'-8$%79A)#)*'+&92*#)#"#4'#84':$)9'5%)@4%*'&6'+$%5)&@$*+".$%'%)*P>'!.&&5'-%4**"%4'*+%449)9A')9'$*7:-#&:$#)+')95)@)5"$.*'+$9'84.-')549#)67'-4&-.4'<)#8'87-4%#49*)&9'346&%4'#847'54@4.&-'4952&%A$9'+&:-.)+$#)&9*>'b6'+&"%*4C'*+%449)9A'<)..')549#)67'$'*-4+#%":'&6'8)A82'$95'.&<2%)*P'-$#)49#*>'L'*#%&9A'+8%&9)+'+$%4'

2)9A'#84'6%$A).4'84$.#8')96%$*#%"+#"%4'<)#8'-$#)49#*'<8&'8$@4'.&<'.4@4.*'&6'87-4%#49*)&9'#8$#'+&964%'.)##.4'%)*P'&6'4952&%A$9'5)*4$*4>'b"%'A&$.')9'*+%449)9A')*'#&')549#)67'8)A82%)*P')95)@)5"$.*'<8&'<&".5'9&#'&#84%<)*4'*44P'#%4$#:49#'346&%4'+&:-.)+$#)&9*'$%)*4>'

G&#49#)$.'&++$*)&9*'6&%'*+%449)9A')9+."54'&--&%#"9)*#)+'3.&&5'-%4*2*"%4':4$*"%4:49#'$#'$+"#4'+$%4'&%'&"#-$#)49#'54-$%#:49#'+.)9)+*'$95'*7*#4:$#)+'3.&&5'-%4**"%4':4$*"%4:49#'37'84$.#8'<&%P4%*')9'#84'+&::"9)#7>'?9'%4*&"%+42-&&%'*4##)9A*C'.$+P'&6'4O")-:49#C'#%$)9)9AC'$95'#):4'+$9'-&*4'3$%%)4%*'#&'):-.4:49#$#)&9'&6'%&"#)94'3.&&5'-%4**"%4':4$*"%4:49#'$#'$97'.4@4.'&6'#84'84$.#8'+$%4'*7*#4:>'T)@49'#84'+&:-4#2)9A'54:$95*'&9'+&::"9)#7'84$.#8'<&%P4%*C'<4'8$@4'6&+"*45')9)#)$..7'&9'*+%449)9A'$#'#84'84$.#82+49#4%'.4@4.>'_4'5&'#8)*')9'#84'+&9#4E#'&6'$+"#4'+$%4'-%&#&+&.*'6&%'#84'?9#4A%$#45'R$9$A4:49#'&6'L5".#'$95'L5&.4*+49#'?..94**>/J'L#'G?,2*"--&%#45'84$.#8'+49#4%*C'<4'49+&"%$A4'-%$+#)#)&94%*'#&':4$*"%4'#84'@)#$.'*)A9*C')9+."5)9A'3.&&5'-%4**"%4C'&6'4@4%7&94'<8&'-%4*49#*'<)#8'$'%&"#)94'+&:-.$)9#>'_4'"*4'@$.)5$#45'$"#&:$#)+'3.&&5'-%4**"%4':$+8)94*'$95'<4'P44-':$9"$.'+"66*'$@$).$3.4')9'+$*4'#84':$+8)94':$.6"9+#)&9*>'!$##4%)4*'&%'4.4+#%)+)#7'+$9'-&<4%'#84':$+8)94*>'L++"%$#4':4$*"%4:49#*'%4O")%4'#%$)9)9A')9'$--%&-%)$#4'+"66'*)^4*'$95'#84'-%&+"%4:49#'&6':$+8)94*'+&:-$#)3.4'<)#8'*:$..C'%4A".$%C'$95'.$%A4'$5".#'+"66*>


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

L*':49#)&945'$3&@4C'87-4%#49*)&9')*'3&#8'@4%7'+&::&9'$95'%4.$#)@4.7'*):-.4'#&'#%4$#>'R&*#'87-4%#49*)&9'-$#)49#*'+$9'34'#%4$#45'$#'#84'84$.#82+49#4%'.4@4.>',&<4@4%C'#84'*"3D4+#'34+&:4*':&%4'+&:-.4E'<849'&94'+&9*)54%*'$..'#84'5)*4$*4*'49+&:-$**45'37'#84'5)$A9&*)*'&6'87-4%#492*)&9>'L#'.&<'.4@4.*'&6'3.&&5'-%4**"%4'4.4@$#)&9C'%)*P'#&'#84'-$#)49#')*'@4%7'.&<'$95'%4O")%45'#%4$#:49#')*'$++&%5)9A.7':)9):$.>'L#'8)A84%'.4@4.*C'87-4%#49*)&9'34+&:4*'$'%$-)5.7'54$5.7'5)*4$*4C'%4O")%)9A'@4%7'$AA%4*2*)@4'#%4$#:49#>'?9'34#<449C'#84%4')*'$'%$9A4'&6':&%4'$95'.4**'*4@4%4'-%4*49#$#)&9*>'H8)*'84#4%&A494)#7'%4*".#*')9'<8$#':$7'$--4$%'#&'34'+&:-.4E'-%&#&+&.*'#&'4E-.$)9'#%4$#:49#'&6'$'*):-.4'-%&3.4:>',&<4@4%C'#8)*'$--%&$+8C'<4'34.)4@4C'%4-%4*49#*'&"%'34*#'$##4:-#'#&'$--%&-%)$#4.7'#$).&%'#%4$#:49#'$++&%5)9A'#&'%)*P'<8).4'$@&)5)9A'"994+4**$%7'#4*#)9A''&%'%464%%$.*>

Give nifedipine immediaterelease 10 mg PO x 1 ORcaptopril 25 mg PO x 1.

Consider Lasix 20 mg IV ORLasix 40 mg PO x 1 if di!culty

breathing

Transfer todistrict hospital

Danger signs: acute dyspnea, visual changes,

headache?

Address primary complaint

BP ≥ 180/110 mmHg

Address primary complaint

Lone Stage 1 140/90–160/100 mmHg WITHOUT high-risk features*

Return to acute care clinic in 12 months for BP

check. Counsel on reducing salt intake and

weight loss if appropriate.

Pregnant(all women

between 15 and49 should be

tested)

Stage 2 160/100–

180/110 mmHg

Return to acute care clinicin 6 months for BP check.Counsel on reducing saltintake and weight loss if

appropriate.* High-Risk Features: - Age ≥ 65 years- Known diabetes - Known renal failure- BMI ≥ 25 kg/m2- Tobacco smoking

≥ 6 mo trial of lifestyle

modification

Any patient with aroutine complaint

presenting to acutecare clinic

NO

YES

YES

NO

YES

NO

NO

NO

NO

YES YES

YES

YES

YES NO

NO

YES

BP ≥140/90 mmHgx2 at rest

Transient cause of HTN present

(e.g., pain, anxiety)

See management of HTN in pregnancy (Protocol 8.5)

Start two anti-hypertensives at initial dose, have follow-up in nearest

health center CCC in 1 week. Communicate appointment to

CCC nurse.

Stage 1 140/90–160/100

mmHg WITH 2 or more high-risk

features*

Refer to nearest CCC clinic in 1–4 weeks for evaluation

of HTN. Communicate appointment to CCC nurse.

BP = Blood pressureCCC = Chronic care clinicHTN = Hypertension


PROTOCOL 8.1 Initial Screening and Management of Hypertension in Acute Consultation Clinics

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8.1.1 Evaluation of Blood Pressure in Acute Care ClinicsL+"#4'+$%4'+.)9)+)$9*'*8&".5'+84+P'#84'3.&&5'-%4**"%4'&6'$97'-$#)49#'-%4*49#)9A'<)#8'$'%&"#)94'+&:-.$)9#>'?6'#84'3.&&5'-%4**"%4':4$*"%4*'.4**'#8$9'/K1id1'::,AC'#84'+.)9)+)$9'-%&+445*'<)#8'#84'@)*)#'$*'"*"$.>'?6'#84'3.&&5'-%4**"%4':4$*"%4*'A%4$#4%'#8$9'/K1id1'::,AC'#84'+.)9)+)$9'%4+84+P*'#84'3.&&5'-%4**"%4C':$P)9A'*"%4'#8$#'#84'-$#)49#')*'$#'%4*#'$95'#8$#'#84'+"66'*)^4')*'$--%&-%)$#4>'

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H84'+.)9)+)$9'#849'4@$."$#4*'#84'-$#)49#=*'.4@4.'&6'87-4%#49*)&9'$95'#%4$#*'$++&%5)9A.7>'

8.1.2 Identification and Treatment of Emergency Conditions in Acute Consultation

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8.1.3 Treatment of Asymptomatic Hypertension by Disease Classification

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?9'$..'+$*4*'&6'%464%%$.'#&'#84'84$.#8'+49#4%')9#4A%$#45'+8%&9)+'+$%4'+.)9)+C'#84'$+"#4'+$%4'+.)9)+)$9':"*#'+&::"9)+$#4'#84'%464%%$.'#&'#84'+8%&9)+'+$%4'+.)9)+)$9C'4)#84%'#8%&"A8'$'*8$%45'<%)##49'-$#)49#'.&A'3&&P'$95i&%'#8%&"A8'#84'4.4+#%&9)+':45)+$.'%4+&%5'*7*#4:>

8.1.3.1 Stage 2 Hypertension (160/100–180/110 mmHg) G$#)49#*'<)#8'*#$A4'J'87-4%#49*)&9'V/Z1i/11k/g1i//1'::,AX'$%4'9&#'*#$%#45'&9'$97':45)+$#)&9*')9'#84'$+"#4'*4##)9A>'H847'$%4'%464%%45'#&'#84'94$%4*#'84$.#8'+49#4%')9#4A%$#45'+8%&9)+'+$%4'+.)9)+')9'$'9&92"%A49#'

)9)#)$#)&9'&6'#84%$-7')9'-$#)49#*'$#'.&<'%)*P'6&%'*8&%#2#4%:'+&:-.)+$#)&9*>'


8.1.3.2 Stage 1 Hypertension (140/90–160/100) with High-Risk Features G$#)49#*'<)#8'*#$A4'/'87-4%#49*)&9'$%4'4@$."$#45'6&%'8)A82%)*P'64$#"%4*'#8$#':$7'<$%%$9#':&%4'$AA%4**)@4'#%4$#:49#'&6'3.&&5'-%4**"%4>',)A82%)*P'64$#"%4*')9+."54'P9&<9'5)$34#4*'&%'%49$.'6$)."%4C'&@4%<4)A8#'V!R?'

TABLE 8.1X>'S.)9)+)$9*'

+&%%4*-&95)9A'!R?'6&%'$..'-$#)49#*'$*'-$%#'&6'$5".#':$.9"#%)#)&9'*+%4492)9A')9'$+"#4'+$%4>'?9'$55)#)&9C'-$#)49#*'$%4'$*P45'$3&"#'#&3$++&'"*4'$95'-%4@)&"*'5)$A9&*)*'&6'5)$34#4*>'?96&%:$#)&9'&9'-%)&%'5)$A9&*4*'+$9'&6#49'34'&3#$)945'6%&:'#84'-$#)49#2+$%%)45':45)+$.'%4+&%5>'

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TABLE 8.1 High-Risk Features in Hypertension

High-risk feature Points

Diagnosis of diabetes 2

Diagnosis of renal failure (creatinine 1) 2

Age 65 years 1

BMI 25 kg/m2 1

Tobacco smoking 1

A total of 2 or more points is considered high risk and warrants more aggressive treatment.

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8.1.3.3 Low-Risk Stage 1 Hypertension G$#)49#*'<)#8'*#$A4'/'87-4%#49*)&9'$95'64<4%'#8$9'#<&'%)*P'-&)9#*'$%4'$#'.&<'%)*P'&6'+&:-.)+$#)&9*'6%&:'#84)%'87-4%#49*)&9>'[&%'#8)*'%4$*&9C'<4'$5@&+$#4'54.$7)9A'-8$%:&+&.&A)+'#%4$#:49#'$95i&%'%464%%$.'#&')9#4A%$#245'+8%&9)+'+$%4'+.)9)+*'6&%'#84*4'-$#)49#*>'H84*4'-$#)49#*'$%4'+&"9*4.45'#&'$@&)5'$5545'*$.#'$95')9*#%"+#45'#&'%4#"%9'#&'#84'$+"#4'+$%4'+.)9)+')9'&94'74$%'6&%'$'%4-4$#'3.&&5'-%4**"%4':4$*"%4:49#>'G$#)49#*'<)#8'$'!R?'

YES

YES

YES

YES

YES

NO

NO

YES

NO

YES

YES

NO

NO

YES YES

NO

NO

YES

NO

BP ≥

180/

110

mm

Hg

AN

Dda

nger

sign

s:

acut

e dy

spne

a, v

isual

cha

nges

, he

adac

he?

Man

age

as h

yper

tens

ive

emer

genc

y(S

ectio

n 8.

4, T

able

8.4

)

Tran

sfer

to

dist

rict h

ospi

tal

See

man

agem

ent o

f hy

pert

ensio

n in

pr

egna

ncy

Patie

nt

refe

rred

to

heal

th c

ente

r CC

C fo

r HTN

Preg

nant

?(w

omen

bet

wee

n 15

and

49

shou

ld b

e te

sted

)

Com

plet

e in

take

form

, ev

alua

te fo

r com

plic

atin

g/co

mor

bid

fact

ors

Sign

s of

hear

t fai

lure

(e

dem

a, d

yspn

ea)

Refe

r to

NCD

cl

inic

for

susp

ecte

d he

art

failu

re(P

roto

col 4

.1)

(Pro

toco

l 8.5

)

Mee

ts cr

iteria

for C

CC re

ferr

al:

(1) B

P ≥

160/

100

mH

g O

R (2

) BP ≥

140/

90 m

mH

g A

ND

≥

2 h

igh

risk

poin

ts* A

ND

fa

iled

tria

l of l

ifest

yle

mod

ifica

tion

Refe

r pat

ient

bac

k to

ur

gent

car

e se

tting

for

BP

rech

eck

in 6

–12

mon

ths

Stag

e 1

(140

/90–

160/

100

mm

Hg)

Stag

e 3

≥ 18

0/11

0m

mH

g

Stag

e 2

160/

100–

18

0/11

0 m

mH

g

Eval

uate

hyp

erte

nsio

n st

age

Star

t one

dru

g at

low

est d

ose.

Ret

urn

to

heal

th c

ente

r CC

C in

3

mon

ths

Chec

k cr

eatin

ine

and

prio

ritiz

e A

CE-I

if no

t co

ntra

indi

cate

d (i.

e.,

preg

nanc

y or

cre

atin

ine ≥

200

µmol

/L)

Dia

betic

Chec

k ur

ine

dips

tick

≥ 2

+ pr

otei

nuria

Refe

r to

dist

rict-

leve

l N

CD c

linic

in 1–

2 w

eeks

See

man

agem

ent o

f di

abet

es

(Cha

pter

7)

BP

goal

will

be

≤ 13

0/80

mm

Hg

NO

BMI ≥

25?

Any

gly

cosu

ria

Chec

k a

confi

rmat

ory

test

fo

r dia

bete

s (f

astin

g bl

ood

gluc

ose

or

hem

oglo

bin

A1C

). If

diab

etes

co

nfirm

ed, B

P go

al w

ill b

e≤

130/

80 m

mH

g(C

hapt

er 7

)

BP =

Blo

od p

ress

ure

CCC

= Ch

roni

c ca

re c

linic

HTN

= H

yper

tens

ion

* Hig

h-Ri

sk F

eatu

res:

D

iabe

tes –

2 p

oint

s R

enal

failu

re –

2 p

oint

s P

rote

inur

ia –

2 p

oint

s T

obac

co sm

okin

g –

1 poi

nt B

MI ≥

25

– 1 p

oint

Age

≥ 6

5 ye

ars –

1 po

int

1. If ≤

40,

che

ck fo

r cau

ses o

f se

cond

ary

HTN

2. St

art t

wo

drug

s at l

owes

t do

se3.

Ret

urn

to h

ealth

cen

ter C

CC

in 3

mon

ths.

In d

istr

ict N

CD cl

inic

:1.

Eval

uate

for s

igns

of h

eart

failu

re. I

f pre

sent

per

form

an

ech

o2.

Che

ck c

reat

inin

e3.

If ≤

40,

con

sider

che

ckin

g fo

r oth

er c

ause

s of

seco

ndar

y H

TN4.

Sta

rt tw

o dr

ugs a

t low

est d

ose.

5. If

no

rena

l or h

eart

failu

re, r

efer

bac

k to

hea

lth c

ente

r CC

C fo

r visi

t in

1–2

wee

ks. O

ther

wise

, ret

urn

to

dist

rict N

CD c

linic

in 1–

2 w

eeks

.


8.2 Initial Management of Newly Referred Hypertension Cases in Health Center Integrated Chronic Care Clinics

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PROTOCOL 8.2 Initial Management of Newly Referred Hypertension Cases in Health Center Integrated Chronic Care Clinics


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8.2.1 Identification and Treatment of Emergency Conditions in the Health Center Integrated Chronic Care Clinic

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8.2.2 Evaluation for Comorbid Conditions in the Health Center Integrated Chronic Care Clinic

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8.2.3 Evaluation of Hypertension Stage in the Health Center Integrated Chronic Care Clinic

L6#4%'$**4**)9A'6&%'+&:&%3)5i+&:-.)+$#)9A'6$+#&%*'$95'4@)549+4'&6'2

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8.2.3.1 Treatment of Higher-Risk Stage 1 Hypertension in the Health Center Integrated Chronic Care Clinic

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8.2.3.2 Evaluation of Proteinuria in Stage 2 and Stage 3 Hypertension in the Health Center Integrated Chronic Care Clinic

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8.2.3.3 Evaluation of Glycosuria in Stage 2 and Stage 3 Hypertension or Overweight Patients in the Health Center Integrated Chronic Care Clinic

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2


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8.2.3.4 Treatment of Stage 2 Hypertension in the Health Center Integrated Chronic Care Clinic

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8.2.3.5 Treatment of Asymptomatic Stage 3 Hypertension in the Health Center Integrated Chronic Care Clinic

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TABLE 8.2 Initiation of Hypertension Treatment According to Stage and Risk Factors

Stage Blood pressure range

Treatment Clinic follow-up

Stage 1AND

1 high risk point (TABLE 8.1)

140/90–160/100 mmHg

Do not start medications.Counsel on salt intake and weight loss if indicated.

12 months in acute care

Stage 1 AND

2 high risk points (TABLE 8.1)ANDNo trial of lifestyle modification

140/90–160/100 mmHg

Do not start medications.Counsel on salt intake and weight loss if indicated.

6 months in acute care

Stage 1 AND

2 high risk points (TABLE 8.1)ANDFailed 6-month trial of lifestyle modification

140/90–160/100 mmHg

Start first-line medication at lowest dose

3 months in health center integrated chronic care clinic

Stage 2 160/100–180/110 mmHg

Start first- and second-line medications at lowest dose

3 months in health center integrated chronic care clinic

Stage 3WITHOUTDanger signs*

180/110+ mmHg Start first- and second-line medications at lowest dose

1–2 weeks in district level NCD clinic

Stage 3WITHDanger signs*

180/110+ mmHg Initiate therapy listed in TABLE 8.4. Transfer to district hospital for inpatient management

* Danger signs include acute dyspnea, visual changes, headaches.

8.3 Recommended Hypertension Medications and Dosing

TABLE 8.3'*8&<*'#84'"*"$.'&%54%')9'<8)+8':45)+$#)&9*'*8&".5'34'*#$%#45'6&%'87-4%#49*)&9':$9$A4:49#>'H8)*'&%54%'<$*'+8&*49'3$*45'&9'*$64#7C'

V*"+8'$*'+&*#X'@$%7'34#<449'+&"9#%)4*C'*&':$7'#84'&%54%)9A'&6'-%464%%45'$9#)287-4%#49*)@4':45)+$#)&9*')9'5)664%49#'*4##)9A*>'APPENDIX B'.)*#*'&"%'+&*#'4*#):$#4*'6&%'4$+8':45)+$#)&9>

?9'#84'-%4*49+4'&6'*&:4'+&:&%3)5'+&95)#)&9*C'*"+8'$*'-%&#4)9"%)$C'%49$.'6$)."%4C'$95'-%4A9$9+7C'5)664%49#':45)+$#)&9*':$7'34'-%464%%45>'H84*4'4E+4-#)&9*'$%4'9&#45')9'#84'#4E#'34.&<'$95')92TABLE 8.552TABLE 8.6C'$95'TABLE 8.11+

Y*#18B=*&02"-0&81+'[&%':&*#'-$#)49#*C'875%&+8.&%&#8)$^)54')*'#84'34*#':45)+$#)&9'#&'*#$%#')9)#)$..7>'?#')*'4E#%$&%5)9$%).7'+84$-C'#$P49'&9.7'&9+4'


2-&P$.4:)$'$%4'.&<>',&<4@4%C')9'*&:4'+)%+":*#$9+4*C'*"+8'$*'-%4A9$9+7C'

V*44'TABLE 8.5C'TABLE 8.6C'"&%'TABLE 8.11X>

Q0',&%B=*&02"-0&81+ 2#)&9'8$*'3449':$E):)^45'<)#8&"#'$+8)4@)9A'$54O"$#4'3.&&5'-%4**"%4'+&9#%&.C'$9&#84%':45)+$#)&9':"*#'34'*#$%#45>'[&%':&*#'-$#)49#*C'#8)*'<)..'34'$9')95)+$#)&9'6&%'*#$%#)9A'$'+$.+)":2+8$994.'3.&+P4%'V*"+8'$*'$:.&25)-)94'&%'9)645)-)94X>'G$#)49#*'<)#8'*#$A4'J'&%'B'87-4%#49*)&9'<)..'.)P4.7'9445'$#'.4$*#'J':45)+$#)&9*'#&'$+8)4@4'3.&&5'-%4**"%4'+&9#%&.>'?9'#84*4'*)#"$#)&9*C'-$#)49#*'*8&".5'34')9)#)$#45'&9'#84'*#$%#)9A'5&*4'&6'3&#8'#84'

Z!*#%B=*&02"-0&81+'?9':$97'-$#)49#*C'#<&':45)+$#)&9*'4@49'$#'#84)%':$E):":'5&*4':$7'9&#'34'49&"A8'#&'$+8)4@4'3.&&5'-%4**"%4'+&9#%&.>'H8)*')*'-$%#)+".$%.7'#%"4'6&%'-$#)49#*'<)#8'*#$A4'B'87-4%#49*)&9>'LSU')928)3)#&%*'V.)*)9&-%).'&%'+$-#&-%).X'$%4'#84'-%464%%45'#8)%52.)94'$A49#'$6#4%'#84':$E):":'5&*4'&6'875%&+8.&%#8)$^)54'$95'$:.&5)-)94'8$@4'3449'%4$+845>'LSU')98)3)#&%*'$%4'+&9#%$)95)+$#45')9'-%4A9$9+7'$95'*4@4%4'

Y,<#8!B=*&02"-0&81+'Y&:4'-$#)49#*':$7'8$@4'87-4%#49*)&9'#8$#')*'-$%#)+".$%.7'%4*)*#$9#'#&'3.&&5'-%4**"%4':45)+$#)&9*>'[&"%':45)+$#)&9*'6&%'87-4%#49*)&9':$7'34'944545>'?9'A494%$.C'$#49&.&.')*'#84'6&"%#82.)94'$9#)87-4%#49*)@4'&6'+8&)+4>'L.#8&"A8')#')*')94E-49*)@4C'#84'4664+#)@494**'&6'$#49&.&.')9'%45"+)9A'+49#%$.'3.&&5'-%4**"%4'$95'-%4@49#)9A'$5@4%*4'+$%5)&@$*+".$%'&"#+&:4*'8$*'3449'+$..45')9#&'O"4*#)&9>/B

Y*C8!B=*&02"-0&81+'H84*4':45)+$#)&9*'*8&".5'%$%4.7'34'"*45'6&%'87-4%22

64+#)@4C':4#87.5&-$'$95'875%$.$^)94'%4O")%4':".#)-.4'5&*4*'-4%'5$7'$95'

#84*4':45)+$#)&9*'$%4'6%4O"49#.7'#84':&*#'$@$).$3.4')9'%4*&"%+42-&&%'*4##)9A*'5"4'#&'#84)%'*$64#7')9'-%4A9$9+7'V*44'SECTION 8.8X>


TABLE 8.3 Recommended Hypertension Medications and Dosing for Most Adult Patients

First-line drug Starting dose Increase dose by

Maximum dose

Notes

Hydrochlorothiazide 12.5 mg 1x/day 12.5 mg 1x/day 25 mg 1x/day Can cause hypokalemiaNot e#ective in the setting of severe renal failure (creatinine 300 µmol/L)

Second-line drug Starting dose Increase dose by

Maximum dose

Notes

Amlodipine 5 mg 1x/day 5 mg 1x/day 10 mg 1x/day Can cause lower-extremity edema

Third-line drug Starting Dose Increase dose by

Maximum dose

Notes

Lisinopril 5 mg 1x/day 5 mg 1x/day 20 mg 1x/day Contraindicated in pregnancy and advanced renal failure (creatinine 200 µmol/L)Can cause cough


Fourth-line drug Starting dose Increase dose by

Maximum dose

Notes

Atenolol 25 mg 1x/day 25 mg 1x/day 50 mg 1x/day Contraindicated if heart rate 55 bpmUse with caution in renal failure, since atenolol is renally cleared

Fifth-line drug Starting dose Increase dose by

Maximum dose

Notes

Hydralazine 25 mg 3x/day 25 mg 3x/day 50 mg 3x/day Safe in pregnancyHeadache common side e#ect of hydralazine

Methyldopa 250 mg 2x/day 250 mg 2x/day 500 mg 2x/day Safe in pregnancy

8.4 Recognition and Management of Hypertensive Emergency

L+"#4'%)*4*')9'3.&&5'-%4**"%4'+$9'%4*".#')9'4952&%A$9'5$:$A4')9'$':$#2#4%'&6'8&"%*>'H84*4'87-4%#49*)@4'4:4%A49+)4*'"*"$..7'&++"%'$#'3.&&5'-%4**"%4*'$3&@4'/g1'::,A'*7*#&.)+'&%'//1'::,A'5)$*#&.)+>'Y)A9*'&6'$'87-4%#49*)@4'4:4%A49+7')9+."54'84$5$+84'$95'3."%%45'@)*)&9'+$"*45'37')9+%4$*45')9#%$+%$9)$.'-%4**"%4C'57*-94$'+$"*45'37'$9'$+"#4'*#)6649)9A'

-$)9'+$"*45'37')9D"%7'#&'#84'P)5947*>'

G$#)49#*'%4-&%#)9A'*"+8'*7:-#&:*'<)#8'3.&&5'-%4**"%4'&@4%'/g1i//1'::,A'*8&".5'34'#%4$#45')::45)$#4.7'<)#8':45)+$#)&9*'#&'.&<4%'#84)%'

3&57'$5D"*#*'#&'87-4%#49*)&9'&@4%'#):4C'.&<4%)9A'3.&&5'-%4**"%4'#&&'


2%$#)&9>'TABLE 8.4'.)*#*':45)+$#)&9*'%4+&::49545'6&%'$+"#4':$9$A4:49#'&6'87-4%#49*)@4'4:4%A49+7>

L..'-$#)49#*'<)#8'*"*-4+#45'87-4%#49*)@4'4:4%A49+7'*8&".5'34'#%$9*264%%45'#&'#84'94$%4*#'5)*#%)+#'8&*-)#$.'6&%')9-$#)49#':$9$A4:49#>

TABLE 8.4 Recommended Medications for Management of Hypertensive Emergency (Adult Dosing)

Medication Dosing Notes

Nifedipine (immediate release)

10 mg orally

Captopril 25 mg orally Contraindicated in pregnancy and severe renal failure (Cr 200 µmol/dL)

Hydralazine 25 mg orally

Furosemide 40 mg orally or 20 mg IV If evidence of pulmonary congestion

8.5 Renal Dysfunction in Hypertension

,7-4%#49*)&9'$95'%49$.'57*6"9+#)&9'&6#49'+&4E)*#>'_849'#84'P)5947*'

:$7')9+%4$*4>',7-4%#49*)&9':$7'$.*&'.4$5'#&'%49$.'6$)."%4'37'-"##)9A'2

*"%4'<)#8'$9#)87-4%#49*)@4*'+$9'*.&<'#84'-%&A%4**)&9'&6'%49$.'5)*4$*4>',&<4@4%C'+4%#$)9':45)+$#)&9*'$%4'4)#84%'5$9A4%&"*'&%'9&'.&9A4%'<&%P'<4..')9'#84'*4##)9A'&6'%49$.'6$)."%4C'$*'4E-.$)945'34.&<>


TABLE 8.5 Hypertension Medications and Dosing in Setting of Proteinuria or Mild Renal Failure (Creatinine 100–200 !mol/L)


Maximum dose

Notes

Lisinopril 5 mg 1x/day 5 mg 1x/day 20 mg 1x/day Contraindicated in pregnancy and advanced renal failure (creatinine 200 µmol)Can cause cough



Maximum dose

Notes

Hydrochlorothiazide 12.5 mg 1x/day 12.5 mg 1x/day 25 mg 1x/day Can cause hypokalemia Not e#ective in the setting of severe renal failure (creatinine

300 µmol)

Third-line drug Starting dose Increase dose by

Maximum dose

Notes



Maximum dose

Notes

Atenolol 25 mg 1x/day 25 mg 1x/day 50 mg 1x/day Contraindicated if heart rate 55 bpm

Use with caution in renal failure as is renally cleared

Fifth-line drug Starting dose Increase dose by

Maximum dose

Notes

Hydralazine 25 mg 3x/day 25 mg 3x/day 50 mg 3x/day Safe in pregnancy. Headache common side e#ect


8.5.1 Proteinuria or Mild Renal Failure (Creatinine between 100–200 !mol/L)

G%&#4)9"%)$')*'$9'4$%.7'*)A9'&6'%49$.'57*6"9+#)&9>'R).5'%49$.'6$)."%4')*'#7-)+$..7'-%4*49#'$#'+%4$#)9)94'.4@4.*'34#<449'/11'$95'J11'n:&.iF>'LSU')98)3)#&%*'84.-'54+%4$*4'-%&#4)9"%)$'$95'-%4@49#'6"%#84%'%49$.'5$:$A4'

$..'-$#)49#*'<)#8'-%&#4)9"%)$'&%':).5'%49$.'6$)."%4'"9.4**'+&9#%$)95)+$2

>


TABLE 8.6 Recommended Hypertension Medications and Dosing in Setting of Severe Renal Failure (Creatinine 200 !mol/L)


Maximum dose

Notes

If Cr 300 µmol/L

Hydrochlorothiazide 12.5 mg 1x/day 12.5 mg 1x/day 25 mg 1x/day Can cause hypokalemia

If Cr 300 µmol/L

Furosemide 20 mg 1x/day 20 mg 1x/day 40 mg 1x/day


Maximum dose

Notes



Maximum dose

Notes

Atenolol 25 mg 1x/day 25 mg 1x/day 100 mg 1x/day Contraindicated if heart rate

55 bpmUse with caution in renal failure


Maximum dose

Notes

Hydralazine 25 mg 3x/day 25 mg 3x/day 50 mg 3x/day Safe in pregnancyHeadache common side e#ect


,&<4@4%C')9'#84'+$*4'&6'4@49':&%4'*4@4%4'%49$.'57*6"9+#)&9'V+%4$#)9)94''

#8)*'*+49$%)&C'$'.&&-'5)"%4#)+'V6"%&*4:)54X'*8&".5'34'*"3*#)#"#45'$*'#84'

$%4'$.*&'*$64')9'%49$.'6$)."%4C'$95'*8&".5'34'#84'94E#'+8&)+4>'L#49&.&.'+$9'$.*&'34'"*45C'3"#'#84'5&*4'*8&".5'9&#'4E+445'01':Ai5$7')9'#84*4'-$#)49#*>'H8)*')*'34+$"*4'$#49&.&.')*'4E+%4#45'37'#84'P)5947*>'LSU')98)3)2#&%*'$95'*-)%&9&.$+#&94'*8&".5'34'$@&)545'5"4'#&'#84'%)*P'&6'87-4%P$.42:)$>'!4+$"*4'#84*4'-$#)49#*'$%4'$#'%)*P'6&%':".#)-.4'+&:-.)+$#)&9*C'#847'*8&".5'34'6&..&<45'$#'#84'.4@4.'&6'#84'5)*#%)+#'8&*-)#$.>

Patient ≤ 40 years old and SBP ≥ 160 mmHg and DBP ≥ 100 mmHg

Check creatinine and potassium(if available)

Creatinine ≥ 200 µmol/L Hypertension likely secondary to renal

failure. See Section 8.5

Evaluate for other causes of secondary hypertension and refer to endocrinologist1. Cushingnoid features2. Signs of hyperaldosteronism (low potassium)3. Signs of coarction (delayed or absent femoral pulse, SBP in legs 40 mmHg ≤ than in arms)4. Symptoms of pheochromocytoma (periodic episodes of hypertension, anxiety, tachycardia, diaphoresis)5. Signs of renal artery stenosis (abdominal bruit, creatinine more than doubles after starting ACE-I)

NO

YES


8.6 Evaluation and Management of Hypertension in Younger Patients

R&*#'4**49#)$.'87-4%#49*)&9'<)..'&++"%')9'-$#)49#*'&@4%'#84'$A4'&6'K1>'?6'$'-$#)49#'-%4*49#*'<)#8':&54%$#4'#&'*4@4%4'87-4%#49*)&9'$#'$'7&"9A4%'$A4C'*4+&95$%7'+$"*4*'&6'87-4%#49*)&9'$%4':&%4'.)P4.7'#&'34'$'+$"*4'V*44'TABLE 8.7X>'PROTOCOL 8.3'&"#.)94*'$'5)$A9&*#)+'$--%&$+8'#&'#84*4'-$#)49#*>'

PROTOCOL 8.3 Initial Diagnosis and Management of Suspected Secondary Hypertension

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

TABLE 8.7 Causes of Secondary Hypertension

Cause Findings Management

Renal failure Elevated creatinine ( 200) See SECTION 8.5

Cushing’s syndrome (hypercortisolism)

Truncal obesity, round face, extremity wasting, hypokalemia

Refer to tertiary referral center for endocrinology consultation

Hyperaldosteronism Hypokalemia Refer to tertiary referral center for endocrinology consultation

Pheochromocytoma Periodic episodes of hypertension, anxiety, tachycardia, diaphoresis

Refer to tertiary referral center for endocrinology consultation

Coarctation Delayed or absent femoral pulse; SBP in legs 40 mmHg than SBP in arms

Refer to tertiary referral center for echocardiography and cardiology consultation

Renal artery stenosis Abdominal bruit; creatinine more than doubles after starting ACE inhibitor

Refer to tertiary referral center for renal ultrasound and nephrology consultation

YES

YES

NO

NO

NO

NO

YES

YES

YES

NO

NO

YES

YES

YES

NO

YES

NO

BP ≥ 180/110 mmHg AND

danger signs: acute dyspnea, visual changes,

headache?

Treat as hypertensive emergency (Section 8.4 and Table 8.4)

Transfer to district hospital

See management of hypertension in pregnancy

(Section 8.8)

Patient on medications for hypertension

Pregnant?(Test women 15–49 if

suspected)

Complete follow-up form

Controlled (BP ≤ 140/90

mmHg)

Stage 3≥ 180/110

mmHg

Stage 2160/100 –

180/110 mmHg

Evaluate hypertension stage

Continue current therapy.Return to health center CCC in

3–12 months depending on health center refill mechanism

Check creatinine and prioritize ACE inhibitor if not contraindicated

(i.e., pregnancy or creatinine ≥ 200 µmol/L)

Urine dipstick checked in past

year?

Start or increase two drugs by one interval. Return to health center CCC in 3 months

Start or increase two drugs by one interval.Consider assigning a community health worker Refer to district level NCD clinic in 1–2 weeks

Stage 1BP 140/90–

160/100 mmHgStart or increase one drug by one interval. Return to health center CCC in 3 months

Check urine dipstick ≥ 2+ proteinuria

Any glycosuriaCheck a confirmatory test

for diabetes (fasting blood glucose or

hemoglobin A1C)

BP = Blood pressureCCC = Chronic care clinic


8.7 Follow-Up Treatment for Hypertension

PROTOCOL 8.4'&"#.)94*'$9'$--%&$+8'#&'&9A&)9A':$9$A4:49#'&6'-$#)49#*'<8&'$%4'6&..&<45')9'#84'+8%&9)+'+$%4'+.)9)+*'6&%'87-4%#49*)&9>'

PROTOCOL 8.4 Follow-Up Visit for Chronic Hypertension in Health Center Integrated Chronic Care Clinic


*)A9*'&6'87-4%#49*)@4'4:4%A49+7C'$95'#849'6&%'$97'+8$9A4')9'+&:-.)+$#2)9A'&%'+&:&%3)5'6$+#&%*>'H84'+.)9)+)$9'*8&".5'#849'%4@)4<'#84'4664+#)@4294**'$95'$--%&-%)$#494**'&6'#84'+"%%49#':45)+$#)&9'%4A):49>

8.7.1 Management of Well-Controlled Hypertension on Follow-UpG$#)49#*'<)#8'<4..2+&9#%&..45'87-4%#49*)&9'*8&".5'8$@4'#84)%'+"%%49#'%4A):49'+&9#)9"45>'H84*4'-$#)49#*'5&'9&#'9445'#&'34'*449')9'#84'+.)9)+'

:".#)2:&9#8'*"--.)4*'&6':45)+$#)&9'<)#8&"#'+$"*)9A'*#&+P2&"#*>'H84%426&%4C'#84'#):4'34#<449'+.)9)+'@)*)#*'<)..'54-495':&*#.7'&9'#84'5)*-49*)9A'

8.7.2 Follow-Up of Stage 1 Hypertension[&%'-$#)49#*'<)#8'*#$A4'/'87-4%#49*)&9'V34#<449'/K1id1'$95'/Z1i/11'::,AXC'#84'3.&&5'-%4**"%4':45)+$#)&9'*8&".5'34')9+%4$*45'37'&94')9#4%@$.'V*44'TABLE 8.3X>'

8.7.3 Follow-Up of Stage 2 HypertensionG$#)49#*'<)#8'*#$A4'J'87-4%#49*)&9'V34#<449'/Z1i/11'$95'/g1i//1'::,AX'*8&".5'8$@4'#<&':45)+$#)&9*'*#$%#45'&%')9+%4$*45'37'&94')9#4%2@$.'V*44'TABLE 8.3X>'G$#)49#*')9'#8)*'+$#4A&%7'*8&".5'8$@4'$'"%)94'5)-*#)+P'+84+P45'&9+4'$'74$%>'G$#)49#*'<)#8'-%&#4)9"%)$'$95'$'+%4$#)9)94'.4@4.''

2

8.7.4 Follow-Up of Stage 3 HypertensionG$#)49#*'<)#8'*#$A4'B'87-4%#49*)&9'VA%4$#4%'#8$9'/g1i//1'::,AX'*8&".5'$.*&'8$@4'#<&':45)+$#)&9*'*#$%#45'&%')9+%4$*45'37'&94')9#4%@$.'V*44'TABLE 8.3X>'G$#)49#*')9'#8)*'+$#4A&%7'*8&".5'$.*&'8$@4'$'"%)94'5)-*#)+P'+84+P45'&9+4'$'74$%C'$95'-$#)49#*'<)#8'-%&#4)9"%)$'*8&".5'8$@4'$9'LSU')98)3)#&%'*#$%#45'$*'-$%#'&6'#84)%'%4A):49>'G$#)49#*'<)#8'$97'A.7+&*"%)$'

9445'+.&*4%'6&..&<2"-'$95'*8&".5'34'A)@49'$9'$--&)9#:49#'<)#8)9'/kJ'

<&%P4%'#&'-%&@)54'*"--&%#'$95'49*"%4'A&&5':45)+$#)&9'$584%49+4>'

8.8 Hypertension in Pregnancy

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PROTOCOL 8.5'&"#.)94*'$9'$.A&%)#8:'6&%':$9$A4:49#'&6'87-4%#49*)&9'

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TABLE 8.8 Hypertensive Disorders of Pregnancy

Classification Definition Risks Role of antihypertensives

Chronic hypertension

BP 140/90 mmHgANDDiagnosis of hypertension prior to pregnancy or before 20 weeks of gestation

20% will develop preeclampsia22

Placental abruptionIntrauterine growth retardation

Does not reduce the risk of developing preeclampsiaMay reduce risk of maternal cerebral hemorrhage

Gestational hypertension

BP 140/90 mmHgANDDiagnoses or progression of hypertension after 20 weeks of gestationWITHOUTSignificant proteinuriaDefined as 2+ on a urine dipstick

50% will develop preeclampsia23

10% will develop severe preeclampsia

Does not reduce the risk of developing preeclampsiaMay reduce risk of maternal cerebral hemorrhage

Preeclampsia BP 140/90 mmHgANDDiagnosis or progression of hypertension after 20 weeks of gestationANDSignificant proteinuriaDefined as 2+ on a urine dipstick

25% will develop severe preeclampsiaEclampsia (seizures)Maternal stroke

Does not reduce the risk of developing severe preeclampsiaMay reduce risk of maternal cerebral hemorrhage

Severe preeclampsia

PreeclampsiaANDBP 160/110 mmHgOR

3+ proteinuriaORAny symptom of end-organ damage (oliguria, right-upper-quadrant pain, severe persistent headache, cerebral hemorrhage, nausea, pulmonary edema, low platelets [ 100,000], severe intrauterine growth restriction, or transaminitis [ twice normal])

Eclampsia (seizures)Maternal stroke

Does not reduce the risk of developing severe preeclampsiaMay reduce risk of maternal hemorrhage

YES

NO

YES

NO

YES

YES

NOYES

NO

YES

NO

YES

NO

BP ≥ 160/110mmHg

Check urine dipstick, evaluate for signs of preeclampsia or hypertensive emergency*

BP 140/90–160/110 mmHg

Recheck blood pressure at next

prenatal visit

≥ 2+ proteinuria

Initiate anti-hypertensive

treatment (Table 8.11)

Return to clinic in one week

Initiate antihypertensive treatment (Table 8.11)

Gestational age ≥ 20 weeks OR able to palpate

uterine fundus at umbillicus

Manage as chronic hypertension using medications preferred in

pregnancy (Table 8.11) ≥ 3+

proteinuria and/or danger

signs?

Seizures?Initiate MgSO4

(Table 8.9)Transfer to district hospital

for immediate delivery

Transfer to district hospital for prompt delivery

Danger signs?

Woman with positive pregnancy test and blood

pressure ≥ 140/90 mmHg x 2

* Symptoms of preeclampsia and/or hypertensive

emergency Dyspnea Headache Visual changes Right-upper-quadrant pain Nausea/vomiting


PROTOCOL 8.5 Management of Hypertension in Pregnancy

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8.8.2 Hypertension in Later Pregnacy (Gestational Hypertension and Preeclampsia)

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8.8.3 Recognition and Management of Emergent ConditionsG$#)49#*'<8&'$%4'$+#)@4.7'*4)^)9A'&%'8$@4'8$5'*4)^"%4*'5"%)9A'.$#4'-%4A29$9+7'*8&".5'34')::45)$#4.7'*#$%#45'&9':$A94*)":'$95'#%$9*64%%45'#&'#84'94$%4*#'5)*#%)+#'8&*-)#$.'6&%')::45)$#4'54.)@4%7>'Y44'TABLE 8.926&%'.&$5)9A'$95':$)9#49$9+4'5&*)9A>

TABLE 8.9 Loading and Maintenance Dosing of Magnesium Sulfate in Eclampsia and Severe Preeclampsia (Adapted from IMPAC)17,18

Start with loading dose:Inject 4 grams (20 ml of 20% concentration) by IV over 20 minutes.ANDInject 5 grams (10 ml of 50% concentration) mixed with 1 ml of 1%–2% lidocaine IM in each buttock (for a total of 10 grams).If unable to establish IV, give only IM dose as loading dose.

If seizures recur after 15 minutes, give reloading dose:Inject 2 grams of 20% concentration IV over 5 minutes.

Follow with maintenance dose:Inject 5 grams of 50% concentration IM mixed with 1 ml of 1%–2% lidocaine in alternate buttocks every four hours.

Maximum total dose:40 g every 24 hours

Side-effect monitoring:Monitor for respiratory depression (respiratory rate 16), loss of reflexes and decreased urinary output ( 100 ml/4 hrs). Injecting the magnesium too quickly increases the risk of respiratory or cardiac depression.Stop the therapy if the respiratory rate falls below 16 per minute, patellar reflexes are absent, or urinary output is less than 100 mL over 4 hours.For respiratory depression, give calcium gluconate 1 g IV (10 ml of 10% solution) over 10 minutes

Other safety considerationsDo not leave the patient by herself.Place her on her left side.Transfer immediately to district hospital unless delivery is imminent

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8.8.5 Treatment of Preeclampsia According to Disease Classification

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TABLE 8.10 Recommended Medications for Management of Hypertension in Severe Preeclampsia

Medication Dosing Notes

Nifedipine (immediate release) 10 mg orally Fast acting

Methyldopa 250 mg orally Slower acting

8.8.5.1 Mild to Moderate Preeclampsia

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TABLE 8.11 Recommended Hypertension Medications and Dosing in Pregnancy


Maximum dose

Notes

Methyldopa 250 mg 2x/day 250 mg 2x/day 500 mg 2x/day Best-proven safety in pregnancy, cheap, widely available


Maximum dose

Notes

Nifedipine (immediate release)

10 mg 3x/day 20 mg 3x/day 60 mg 3x/day



Maximum dose

Notes

Atenolol 25 mg 1x/day 25 mg 1x/day 100 mg 1x/day Contraindicated if heart rate 55 bpm


Maximum dose

Notes

Hydralazine 25 mg 3x/day 25 mg 3x/day 50 mg 3x/day Headache common side e#ect.Expensive, requires thrice-daily dosing



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chapter 9Rheumatic Heart Disease Prevention

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9.1 Prevention of Acute Rheumatic Fever: Management of Sore Throat

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PharyngitisGroup A

streptococcalpharyngitis

Rheumatic fever20% 2%

chapter!9 | rheumatic heart disease prevention 219

FIGURE 9.1 Progression from Pharyngitis to Rheumatic Fever

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TABLE 9.1 Clinical Decision Rules for Treatment of Pharyngitis

% with GAS not treated

% without GAS overtreated

Rule 1: WHO14

Pharyngeal exudate + tender and enlarged cervical lymph nodes88% 6%

Rule 2: Steinhoff12

Pharyngeal exudate OR enlarged cervical lymph nodes10% 60%

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_4'8$@4'54@4.&-45'$'%".4'3$*45'&9'5$#$'6%&:'#84'UA7-#)$9'4E-4%)49+4')9'*+8&&.2$A45'+8).5%49C'$95'$.*&'$'S$9$5)$9'+.)9)+$.'54+)*)&9'%".4'#4*#45')9'-&-".$#)&9*'34#<449'#84'$A4*'&6'B'$95']Z'VPROTOCOL 9.1X>

Assess for danger signs:1. Leaning forward and drooling2. Unable to swallow3. Stridor

Refer to district hospital immediately

≥ 2 of Following:1. Lymphandenopathy

2. Documented fever ≥ 383. Lack of cough

Runny nose?Cough?

Congestion?

Patient with a sore throat

YES

YES

NO

YES

Exudate?

Childbetween

5 and 15 yearsold?

Test for HIV if not recently testedor if has risk factors

YES

NO

NO

NO

YES

Runny nose?Cough?

Congestion?

Do not treat for streptococcus.Treat according to acute care

guidelines for respiratorycomplaints (see IMCI and

IMAI guidelines)

YES

NO

Treat as streptococcal pharyngitis(see Tables 9.2 and 9.3)

Treat as streptococcal pharyngitis

(see Tables 9.2 and 9.3)


PROTOCOL 9.1 Evaluation and Management of Pharyngitis

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+&::"9)#7'*4##)9AC'&%$.'#84%$-7')*'$'34##4%'+8&)+4C'$.#8&"A8'6%4O"49#.7'+8).5%49'<)..'*#&-'#$P)9A'#84)%':45)+$#)&9'&9+4'*7:-#&:*'):-%&@4>'?6'$584%49+4'<)#8'&%$.'#84%$-7')*'64.#'#&'34'-&&%C'+&::"9)#7'84$.#8'<&%P24%*'*8&".5'+&9#)9"4'6&..&<2"-'&6'#84*4'+$*4*'"9#).'#84'$9#)3)&#)+'%4A):49')*'+&:-.4#45>'TABLE 9.2'$95'TABLE 9.3'*8&<'#7-)+$.'%4A):49*'6&%'-8$%792A)#)*'#%4$#:49#'$95'#84)%'$**&+)$#45'+&*#*'$95'%)*P*>

TABLE 9.2 Antibiotic Regimens for Streptococcal Pharyngitis (Adults and Adolescents Dosing, Weight 27 kg)

Regimen Doses Cost Allergic Reactions16,17

Oral penicillin VK 500 mg, two times per day for 10 days

20 $0.66 Cutaneous 1%–2%

Intramuscular benzathine penicillin G

1.2 million units, single dose 1 $0.14 Cutaneous 1%–2%

Anaphylaxis 0.02%

Death 0.003%

Oral erythromycin (75 kg adult)

250 mg, four times per day 12 $6.38

TABLE 9.3 Antibiotic Regimens for Streptococcal Pharyngitis (Pediatric Dosing, Weight 27 kg)

Regimen Doses Cost

Oral penicillin VK 250 mg, two times per day for 10 days 20 $0.33

Intramuscular benzathine penicillin G 600,000 units, single dose 1 $0.09

Oral erythromycin (25-kg child) 12.5 mg/kg, three times per day 9 $0.27

9.2 Preventing Rheumatic Heart Disease: Management of Acute Rheumatic Fever and Secondary Prophylaxis for Rheumatic Fever

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9.2.1 Acute Rheumatic Fever: Diagnosis and Follow-Up

+.)9)+*')549#)67';['+$*4*>'G$#)49#*'$%4'#849'%464%%45'#&'#84'94$%4*#'5)*#%)+#'8&*-)#$.'6&%'$5:)**)&9>'L#'5)*+8$%A4C'-$#)49#*'$%4'*49#'#&'#84)%'94$%4*#'+8%&9)+'+$%4'+.)9)+'6&%'6&..&<2"->

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TABLE 9.4 Modified Jones Criteria for High-Risk Groups21,23,24

Major criteria (five) Minor criteria (four)

1. Carditis or subclinical (echocardiographic) carditis2. Polyarthritis or monoarthritis3. Chorea4. Erythema marginatum5. Subcutaneous nodules

Clinical1. Fever 38˚C2. Arthralgia

Laboratory3. Elevated acute phase reactants (erythrocyte

sedimentation rate 30 mm/h)4. PR-interval prolongation

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TABLE 9.5 Antibiotic Regimens for Secondary Prophylaxis of Rheumatic Fever

Adults ( 27 kg) Children ( 27 kg)

Oral penicillin VK 500 mg, two times per day 250 mg, two times per day

Intramuscular benzathine penicillin G 1.2 million units, once every 4 weeks

600,000 units, once every 4 weeks

Oral erythromycin (penicillin allergy) 250 mg, two times per day 10 mg/kg, twice per day

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9.3 Rheumatic Heart Disease Screening

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9.3.1 Echocardiographic Screening for Rheumatic Heart DiseaseY)9+4'#84')9#%&5"+#)&9'&6'4+8&+$%5)&A%$-87')9'#84'/dg1*C')#'8$*'34+&:4')9+%4$*)9A.7'$--$%49#'#8$#'.)*#49)9A'6&%'84$%#':"%:"%*')*'9&#'$'%4.)$3.4'

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TABLE 9.6 Echocardiographic Prevalence of Definite and Possible RHD in School-Aged Children

Country N Setting Population Definite or probable RHD

Possible RHD

Paar et al. 2010 41 Nicaragua 3150 Rural and urban

Community 0.6% 2.4%

Steer et al. 2009 37 Fiji 3462 Rural and urban

School-based 0.8% n/a

Carapetis et al. 2008 39 Tonga 5053 Rural and urban

School-based 3.3% 0.5%

Marijon et al. 2007 36 Cambodia 3677 Urban School-based 3.0% n/a

Marijon et al. 2007 36 Mozambique 2170 Urban School-based 2.1% n/a

Anabwani and Bonhoe#er 1996 42

Kenya 1115 Rural and urban

School-based 0.3% 7.3%

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TABLE 9.7 Echocardiographic Features of Left-Sided Heart Valves Thought Consistent with Rheumatic Heart Disease in High-Prevalence Settings by Three Sets of Criteria

World Health Organization 2001 24

Marijon et al. 2009 44

Preliminary World Health Organization/United States National Institutes of Health 2005 37

Properties of regurgitant jet

Holosystolic (mitral) or holodiastolic (aortic) regurgitation visible in at least two color planes with 1 cm extension and a velocity 2.5 m/s

Any degree in two planes

Definite Probable

2 cm, otherwise meeting World Health Organization 2001 criteria*

2 cm, otherwise meeting World Health Organization 2001 criteria*

Morphologic abnormalities

Not required Required** Required*** Not Required***†

Pathologic murmurs

Not required Not Required Required Required

* 1 cm of jet length is su$cient for aortic regurgitation.** Any two of the three that include leaflet tethering, leaflet thickening, or sub-valvular thickening.*** For mitral regurgitation, these include thickening of the valve or a hockey-stick/elbow deformity of the anterior leaflet; in

addition, for mitral stenosis, these also include tethering of the posterior leaflet, commissural thickening and calcification with a mean gradient 4 mmHg; for aortic regurgitation without obvious non-rheumatic causes, these include morphologic abnormalities of the mitral valve.

† Either significant left-sided valvular regurgitation, morphologic abnormalities, or mitral stenosis in the presence of patho-logic murmurs.

!4+$"*4'&6'"9+4%#$)9#7'$3&"#'#84'):-&%#$9+4'&6':).5'.4*)&9*'&9'4+8&2+$%5)&A%$-87C'<4'-%&-&*4'#8$#'-%4@$.49+4'*"%@47*'-.$+4':&%4'<4)A8#'&9'

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Hig

h-ris

k gr

oup

(Chi

ldre

n ag

es 5

–15)

Follo

w-u

p pl

an fo

r oth

er

iden

tified

con

ditio

ns

NO

Refe

r to

dist

rict

NCD

clin

icYE

SD

efini

te

RHD

?

1. In

itiat

e ant

ibio

tic

prop

hyla

xis (

oral

or I

M)

2. A

ssig

n a

com

mun

ity

heal

th w

orke

r3.

Mon

thly

follo

w-u

p at

he

alth

cen

ter c

hron

ic

care

clin

ic.

YES

1. Co

unci

l reg

ardi

ng so

re

thro

at m

anag

emen

t2.

Par

ticip

ate

in ra

ndom

ized

tr

ial o

f ant

ibio

tics i

f ava

ilabl

e3.

Ass

ign

a co

mm

unity

he

alth

wor

ker

4. F

ollo

w-u

p ev

ery

6 m

onth

s at

dist

rict N

CD c

linic

.

NO

1. H

istor

y: a

ny re

colle

ctio

n of

seve

re jo

int p

ain,

sh

ortn

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f bre

ath.

Con

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scre

enin

g qu

estio

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r epi

leps

y, m

uscu

losk

elet

al

disa

bilit

ies,

asth

ma

2. P

hysic

al e

xam

inat

ion:

hei

ght a

nd w

eigh

t, au

scul

tatio

n. C

onsid

er p

hysic

al e

xam

inat

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for o

ther

con

ditio

ns (e

.g., s

kin

infe

ctio

ns)

3. C

onsid

er sc

reen

ing

labo

rato

ry te

sts f

or

anem

ia, p

rote

inur

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IV4.

Scre

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pa

rast

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g an

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t ech

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raph

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Crite

ria fo

r defi

nite

or p

ossib

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RHD

? (s

ee T

able

9.5

)


PROTOCOL 9.2 Screening for Rheumatic Heart Disease (and Other Conditions of School-Aged Children)

TABLE 9.8 Proposed Criteria for Definite and Possible RHD

Definite Possible

Properties of regurgitant jet At least mild-to-moderate regurgitation. Regurgitation visible in at least two color planes

Any degree in two planes

Morphologic abnormalities Required* Required*

Pathologic murmurs Not required Not Required


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chapter 10Chronic Respiratory Disease

10.1 The Burden of Chronic Respiratory Disease in Rural Rwanda

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10.1.1 The Impact of Biomass Fuels and Tuberculosis on Chronic Respiratory Disease

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10.2 Integration of Chronic Respiratory Disease Management at Health-Center Level

R$97'%4*&"%+4*'4E)*#'6&%'*"32Y$8$%$9'L6%)+$9'+&"9#%)4*'*44P)9A'#&'):-%&@4'*4%@)+4*'6&%'+8%&9)+'%4*-)%$#&%7'5)*4$*4'$#'#84'84$.#82+49#4%'.4@4.>//2/Z'H84*4'%4*&"%+4*')9+."54'-%$+#)+4'A")54.)94*'6%&:'#84'T.&3$.'?9)#)$#)@4'6&%'L*#8:$'$95'#84'T.&3$.'?9)#)$#)@4'6&%'S8%&9)+'b3*#%"+#)@4'F"9A'()*4$*4>/]C/g'H84'?9#4%9$#)&9$.'a9)&9'LA$)9*#'H"34%+".&*)*'$95'F"9A'()*4$*4'V?aLHF(X'8$*'-%4-$%45'A")54.)94*'$95'#%$)9)9A':$#4%)$.*'6&%'$*#8:$':$9$A4:49#')9'%4*&"%+42-&&%'*4##)9A*>/d'H84'?aLHF('8$*'$.*&'4*#$3.)*845'$9'$*#8:$'5%"A'6$+).)#7'#8$#'-%&@)54*')98$.45'+&%#)+&*#42%&)5*'$#'.&<4%'+&*#'#8$9'<8$#')*'&6#49'$@$).$3.4'&9'#84':$%P4#')9':$97'+&"9#%)4*>J1CJ/'H84'Y#&-'H!'54-$%#:49#')9'#84'_&%.5',4$.#8'b%A$9)^$2#)&9'V_,bX'8$*')9+&%-&%$#45'$'-%&A%$:'+$..45'#84'G%$+#)+$.'L--%&$+8'

-".:&9$%7'#"34%+".&*)*>JJ'

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10.2.1 Initial Evaluation for Chronic Respiratory Disease at Health-Center Level

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?9'&"%':&54.C':&*#'+8%&9)+'%4*-)%$#&%7'5)*4$*4':$9$A4:49#'<)..'#$P4'-.$+4'$#'#84'.4@4.'&6'#84'84$.#8'+49#4%')9#4A%$#45'+8%&9)+'+$%4'+.)9)+>'H84*4'+.)9)+*'$.*&'*44'-$#)49#*'<)#8'$'@$%)4#7'&6'+8%&9)+')..94**4*'<)#8'%4.$#)@4.7'*):-.4'#%4$#:49#'$.A&%)#8:*C'*"+8'$*':&*#'+$*4*'&6'87-4%#492*)&9C'4-).4-*7C'9&92)9*".)9'54-49549#'5)$34#4*C'#"34%+".&*)*C'$95',?\>'

YES

NO

NO

YES

YES

NO

YES

NO

YES

NO

YES

YES

NO

Initial evaluation:Chronic cough or

shortness of breath (≥ 3 weeks)

Respiratory rate ≥ 30/minAND wheezing OR

Patient acutely short of breath ORNot able to walk unaided OR

Fever ≥ 39

Fever, chills,productive

cough or HIV+

Serotest in pastyear?

Perform HIV test

Leg swelling, orthopnea, known

heart condition, murmur

Refer to district hospital NCD clinic for confirmation of suspected heart failure

Conjunctival pallor, post-

partum or other history of bleeding

Wheezing, night cough, worsened

by climate change or exercise

Refer to health center integrated chonic care clinic for probable

asthma or COPD (see Protocol 10.2)

1. Obtain CXR2. Obtain sputum smear x 3

Improvement?Cause of dyspnea

was likely pneumonia

1. Position (sit upright/leaning forward)2. If wheezing, give salbutamol 2 sprays every 15 min by

metered dose inhaler with spacer3. If known heart disease and uncomfortable lying down,

give furosemide (refer to acute decompensated heart failure protocol)

4. Refer urgently to district hospital

1. Treat with antibiotics (Adult dosing: doxycycline 100 mg 2x/day x 14 days or amoxicillin 500 mg 3x/day x 14 days)

2. If wheezing, salbutamol inhaler3. Have return in 1–2 weeks

1. Check hemoglobin if available2. Start elemental iron, Adults: 60 mg 2x/day,

Children ≤ 40 kg: 2–3 mg/kg 1x/day3. Albendazole 400 mg 2x/day x 7 days

chapter!10 | chronic respiratory disease 237

PROTOCOL 10.1'&"#.)94*'#84'$--%&$+8'$5&-#45'$#'G?,2*"--&%#45'*)#4*'6&%'#84')9)#)$.'5)$A9&*)*'$95':$9$A4:49#'&6'+8%&9)+'%4*-)%$#&%7'+&:-.$)9#*'#8$#'-%4*49#'#&'$+"#4'+$%4'+.)9)+*'$#'84$.#8'+49#4%*>'

PROTOCOL 10.1 Initial Management of Chronic Cough or Shortness of Breath at Health Center Acute Care Clinics


10.2.2 Identification and Treatment of Emergency Conditions2

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TABLE 10.1 Evaluation of Asthma Attack Severity (Adapted from IUATLD Guidelines)19

Symptoms Mild asthma attack

Moderate asthma attack

Severe asthma attack

Imminent respiratory failure

Dyspnea With physical exertion

With speaking All the time All the time

Can speak in Full sentences Phrases Words Unable to speak

Mental status Normal Normal or agitated

Agitated Somnolent or confused

Respiratory rate Normal to fast Fast Very fast ( 30 breaths/min)

Very fast ( 30 breaths/min)

Pulse 100 100–120 120 Bradycardic

Peak expiratory flow (PEF) after salbutamol (% of patient’s best PEF or predicted PEF)

70% 50%–70% 50% or 100 liters/min

Cannot measure

10.2.3 Exclusion of Causes Other Than Asthma and COPD?9'#84'%"%$.'84$.#8'+49#4%'+.)9)+C'.$+P'&6'5)$A9&*#)+'#&&.*'$95'8)A8'-%4@$2.49+4'&6')964+#)&"*'%4*-)%$#&%7'5)*4$*4'94+4**)#$#4'4E+."*)&9'&6'&#84%'5)*4$*4*'346&%4':$P)9A'#84'5)$A9&*)*'&6'SbG('&%'$*#8:$>'[&%'#84':&*#'-$%#C'#8)*'+$9'34'5&94'37'#$P)9A'$'+$%46".'8)*#&%7'&6'*7:-#&:*>'S4%2#$)9'*7:-#&:*'*8&".5'-%&:-#'6"%#84%'#4*#)9A>'TABLE 10.2'&"#.)94*'#84'+&::&9'+$"*4*'&6'+8%&9)+'%4*-)%$#&%7'*7:-#&:*'V.$*#)9A':&%4'#8$9'B'<44P*X'*449'$#'&"%'+.)9)+*>


TABLE 10.2 Causes of Chronic Dyspnea or Chronic Cough ( 3 Weeks)

System Disease Evaluate for

Respiratory Asthma Episodic wheezing

COPD Progressively worsening dyspnea

Bronchiectasis Large volume of purulent sputum

Acute bronchitis/pneumonia Fever, acute dyspnea, productive cough

Pulmonary tuberculosis Cough, hemoptysis, fevers, night sweats, weight loss

Cardiovascular Congestive heart failure Edema, orthopnea, rales

Pulmonary hypertension and right heart failure

Edema, ascites

Gastrointestinal Gastroesophageal reflux disease Symptoms of reflux, heartburn

Hematologic Anemia Conjunctival pallor, measure hemoglobin

Ear, nose, throat Allergic or non-allergic rhinitis Nasal congestion, itchy/watery eyes

Sinusitis (subacute/chronic) Postnasal drip, headache, rhinorrhea

Psychological Anxiety Dyspnea and chest tightness in social situations, palpitations, sweating, tingling in arms or fingers

Medication ACE inhibitors Usually non-productive cough shortly after starting the medication, though can occur at any time

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10.3 Diagnosis and Initial Management of Chronic Respiratory Disease in Health Center Integrated Chronic Care Clinics

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NO

NO

YES

YES

YES

NO

Complete history and physical exam, including peak flow measurement

1. Patient acutely short ofbreath and wheezing OR

2. RR ≥ 30 bpm

Assess asthmaseverity

(see Table 10.4)

Patient withsevere

asthma orCOPD

Patientwith typical

asthma symptoms,abnormal peak flow

or wheezing onexam?

Patient referred to health center

chronic care clinic (CCC) for suspected

asthma or COPD

1. Position (sit upright/leaning forward)2. Give salbutamol 2 sprays every 15 min by metered dose inhaler

using a spacer3. If has productive cough or fever, give dose of doxycycline 100 mg

or amoxicillin 500 mg (adult dosing)4. Give dose of prednisolone 2 mg/ kg (max 60 mg)5. Refer urgently to district hospital

1. Start appropriate asthma treatment (see Table 10.6 ) and give inhaler teaching2. Abendazole 400 mg 2x/day x 3 days if not treated within the last year3. Education about avoidance of triggers4. Follow-up in health center CCC 2 weeks5. Obtain CXR within next 6 months

1. Start appropriate asthma treatment (see Table 10.6) and give inhaler teaching

2. Albendazole 400 mg 2x/day x 7 days if not treated within the last year (adults)

3. Obtain sputum smear x 34. Refer to district hospital NCD clinic for CXR,

echocardiography and higher-level evaluation

1. Consider alternative diagnosis, including hyperventilation/somatization

2. May give trial of salbutamol3. Follow up in health center CCC

2 weeks –2 months for reassessment


PROTOCOL 10.2 Initial Management of Asthma or COPD at Integrated Chronic Care Clinics

TABLE 10.3 Common Signs and Symptoms of Asthma

Symptoms are intermittent

Symptoms triggered by changes in weather, exposure to dust, exhaust, exercise or cooking smoke

Dyspnea

Wheezing

Cough NonproductiveNighttime

Chest tightness

Reduced PEF in setting of symptoms, 20% improvement with bronchodilators


TABLE 10.4 Classification of Asthma Severity at Initial Visit26

Components of severity Intermittent Persistent

Mild Moderate Severe

Impairment Symptoms 2 days/week 2 days/week but not daily

Daily Throughout the day

Nighttime awakenings None 1–2x/month 3–4x/month 1x/week

Salbutamol use for symptom control

2 days/week 2 days/week but not daily

Daily Several times per day

Interference with normal activity

None Minor limitation

Some limitation

Extremely limited

Risk Exacerbations requiring oral systemic cortico-steroids (prednisolone)

0–1/year 2 exacerbations in 6 months requiring oral systemic corticosteroids, or 4 wheezing episodes/year lasting 1 day AND risk factors for persistent asthma

Consider severity and interval since last exacerbation. Frequency and severity may fluctuate over time. Exacerbations of any severity may occur in patients in any severity category.

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+&95)#)&9*')9'&"%'*4##)9A>'_)#8'#84'4E+4-#)&9'&6'.&9A2$+#)9A'34#$'$A&9)*#*'

TABLE 10.5 Asthma Control Test25

Maximum score is 25 (points are 1–5 in order as below) 19 means asthma may not be well controlled

In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at work, school, or home?

1 All of the time

2 Most of the time

3 Some of the time

4 A little of the time

5 None of the time

During the past 4 weeks, how often have you had shortness of breath?

1 More than once a day

2 Once a day

3 3–6 times a week

4 Once or twice a week

5 Not at all

During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) wake you up at night or earlier than usual in the morning?

1 4 or more nights a week

2 2 or 3 nights a week

3 Once a week

4 Once or twice

5 Not at all

During the past 4 weeks, how often have you used your rescue inhaler (salbutamol)?

1 3 or more times per day

2 1 or 2 times per day

3 2 or 3 times per week

4 Once a week or less

5 Not at all

How would you rate your asthma control during the past 4 weeks?

1 Not controlled at all

2 Poorly controlled

3 Somewhat controlled

4 Well controlled

5 Completely controlled


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54-495*'&9'#84'*4@4%)#7'&6'#84'-$#)49#=*'*7:-#&:*'V*44'TABLE 10.7X>


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TABLE 10.6 Asthma Step Therapy

STEP

-UP

w

hen

poor

con

trol

STEP

-DO

WN

w

hen

doin

g w

ell

Asthma severity Salbutamol Beclomethasone Aminophylline Prednisone

Step 5: Severe uncontrolled Yes High dose Yes Yes

Step 4: Severe persistent Yes High dose Yes No

Step 3: Moderate persistent Yes Medium dose No No

Step 2: Mild persistent Yes Low dose No No

Step 1: Intermittent Yes No No No


10.4 Follow-Up Management of Asthma

PROTOCOL 10.3'&"#.)94*'*"3*4O"49#':$9$A4:49#'&6'-$#)49#*'<)#8'$9'4*#$3.)*845'5)$A9&*)*'&6'$*#8:$>'

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`4E#C'#84'+.)9)+)$9'*8&".5'$*P'#84'-$#)49#*'$3&"#'6%4O"49+7'&6'*7:-2#&:*>'s"4*#)&9*'6%&:'#84'L*#8:$'S&9#%&.'H4*#'V*44'TABLE 10.5X'+$9'34'

-4%6&%:45>'a*)9A'#8)*'5$#$C'#84'+.)9)+)$9'*8&".5'+&9*)54%'8&<'<4..'+&92#%&..45'#84'-$#)49#=*'*7:-#&:*'$%4'$95'54+)54'<84#84%'#84%$-7'*8&".5'34'+&9#)9"45C')9+%4$*45C'&%'54+%4$*45>'

TABLE 10.7 Asthma Medication Dosing

Salbutamol100 mcg (inhaler)

Beclomethasone50 and 250 mcg (inhaler)Always use a spacer

Aminophylline100 mg tab

Prednisone5 mg tab

Adults and children

30 kg

1–2 pu#s, 3x/dayas needed

High:1500 mcg (3 pu#s 2x/d)

300 mgin 3 divided doses

1–2 mg/kg/d in two divided doses (max 60 mg) x 7–10 daysNote:If new CRD diagnosis, first, rule out TB (smear x 3, CXR)

Medium:1000 mcg(2 pu#s 2x/d)

Low:500 mcg (1 pu# 2x/d)

Children 10–30 kg (always use spacers)

1–2 pu#s, 3x/day as needed

High:1000 mcg/d(2 pu#s 2x/d)

n/a 2 mg/kg once per day x 5 days (max 60 mg)

Medium:500 mcg/d (1 pu# 2x/d)

Low:250 mcg/d(1 pu# 1x/d)

Children 10 kg

REFER TO PHYSICIANVery small children should use a metered-dose inhaler with a spacer, or a nebulizer if available.

NO

NO

NO

YES

YES

YES

Patie

nt w

ithdi

agno

sis o

fas

thm

a or

COPD

1. Pa

tient

acu

tely

shor

t of

brea

th a

nd w

heez

ing

OR

2. R

R ≥

30

bpm

Ass

ess d

egre

e of

asth

ma

cont

rol,

com

pare

to la

st v

isit

(see

Tab

le 10

.5)

Step

up

trea

tmen

t(s

ee T

able

10.6

) and

follo

w u

p in

2 w

eeks

1. Co

ntin

ue m

axim

um th

erap

y2.

Ref

er to

dist

rict h

ospi

tal N

CD c

linic

Sym

ptom

impr

ovem

ent?

On

max

imum

ther

apy?

Cont

inue

cur

rent

ther

apy,

retu

rn in

3 m

onth

s

Step

dow

n or

cont

inue

cur

rent

ther

apy

(see

Tab

le 10

.6)

Ther

apy

x 3

mon

ths

1. Po

sitio

n (s

it up

right

/lea

ning

forw

ard)

2. G

ive

salb

utam

ol 2

spra

ys e

very

15 m

in b

y m

eter

ed d

ose

inha

ler w

ith a

spac

er3.

If h

as p

rodu

ctiv

e co

ugh

or fe

ver,

give

dos

e of

dox

ycyc

line

100

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[43%"$%7'J1//

appendix aEssential Equipment and Medicines1,2

A.1 Essential EquipmentEssential equipment Health

centerDistrict hospital

Referral center

Automatic sphygmomanometer (blood pressure machine) with pediatric, small adult, and adult cu#s, and AC adapter

x x x

Glucometer with test strips and lancets x x x

Lab: Chemistry testing (point-of-care) x x

Lab: HbA1c testing (point-of-care) x x

Lab: Hemoglobin testing x x x

Lab: HIV testing x x x

Lab: PT/INR testing (point-of-care) x x

Lab: Urinalysis x x x

Monofilament x x x

Multifunction ultrasound machine (with abdominal, cardiac, and obstetric probes) with ultrasound gel

x x

Nebulizer x x

Peak flow meter x x x

Scale x x x

Tape measure/ruler x x x

Water bottle spacers (for inhaler) x x x

A.2 Essential Medicinesx = Currently recommended by Rwanda MOHt = Recommended for chronic care integration

Pregnancy categories

Category A Controlled studies show no risk, ok to use

Category B No evidence of risk in humans, ok to use

Category C Risk cannot be ruled out, use only if there is no alternative.Potential benefit may outweigh potential risk

Category D Positive evidence of risk, avoid use

Category X Contraindicated in pregnancy, do not use


Palliative care Pregnancy category

Health center

District hospital

Referral center

Analgesia

Acetaminophen/paracetamol B x x x

Amitriptyline C x x

Diazepam D x x x

Diclofenac C x x x

Ibuprofen B x x x

Morphine, liquid preparation C t x x

Phenytoin (Dilantin) D x x

Prednisolone C x x x

Anti-emetics

Chlorpheniramine B x x x

Dexamethasone C x x x

Haloperidol C x x

Metoclopramide B x x x

Promethazine C x x x

Constipation

Bisacodyl C x x x

Glycerine suppository C x x x

Lactulose syrup B x x x

Naloxone B t x x

Diarrhea

Hyoscine butylbromide C x x x

Pruritus

Betamethasone cream C x x x

Permethrin B t x x

Other

Fluoxetine C t x x

appendix a | essential equipment and medicines 259

Heart failure, cardiac surgery, hypertension, anticoagulation, and chronic kidney disease

Pregnancy category

Health center

District hospital

Referral center

Amlodipine C t x x

Aspirin C–D x x x

Atenolol D t x x

Captopril D t x x

Carvedilol C t t tErythromycin B x x x

Furosemide (Lasix) C t x x

Hydralazine C t x x

Isosorbide dinitrate C t t x

Lisinopril D t t tMagnesium sulfate A x x x

Methyldopa A t t x

Nifedipine retard C t t x

Penicillin G benzathine B x x x

Penicillin V B x x x

Propranolol C t t x

Spironolactone (Aldactone) D t t x

Warfarin X t t

DiabetesPregnancy category

Health center

District hospital

Referral center

Amitriptyline C t x x

Glibenclamide (Daonil) C x x x

Insulin Lente (NPH) B x x x

Insulin Rapide (Regular) B x x x

Insulin Mixte (70/30) B x x x

Metformin B x x x


Chronic respiratory diseasePregnancy category

Health center

District hospital

Referral center

Aminophylline C x x x

Beclomethasone inhaler C * * x

Chlorpheniramine B x x x

Doxycycline D x x x

Prednisolone C x x x

Salbutamol inhaler C x x x

EpilepsyPregnancy category

Health center

District hospital

Referral center

Carbamazepine (Tegretol) D x x x

Phenobarbital D x x x

Phenytoin (Dilantin) D * x

Valproic acid (Depakote) D x x

Appendix A!References

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J' F$+7'S[C'L%:*#%&9A'FFC'T&.:$9'RGC'F$9+4'F;C'45*>'F4E)2S&:-=*'(%"A'?96&%:$#)&9',$953&&P'J1/12J1//W'L'S&:-%4849*)@4';4*&"%+4'6&%'L..'S.)9)+)$9*'$95',4$.#8+$%4'G%&64**)&9$.*>'/d#8'U5)#)&9>'J1/12J1//>',"5*&9C'b8)&W'F4E)2S&:-h'J1/1>

appendix bCost Models

H84'-%)+4*'6&%':45)+$#)&9*'.)*#45'84%4'$%4'#84'.&<4*#'&3#$)945'37'G$%#94%*'?9',4$.#8')9';<$95$'6&%'A494%)+*'#8%&"A8'*4@4%$.'5)664%49#'*"--.)4%*>'H84*4'$%4'$+#"$.'-%)+4*'-$)5>'F&<4%'-%)+4*':$7'34'$+8)4@$3.4'#8%&"A8'.$%A4%2*+$.4'-"%+8$*4*'$95'#8%&"A8'5)%4+#'94A&#)$#)&9'<)#8':$9"6$+#"%4%*>

B.1 Summary of Operational Cost Models

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L*'+8%&9)+'+$%4'*4%@)+4*'$%4'54+49#%$.)^45'#&'#84'84$.#82+49#4%'[email protected]'

+&*#*>'L#'#84'*$:4'#):4C'#84'+&"9#%7=*')9#4%9$.'*&"%+4*'&6'%4@49"4'<)..'+&9#)9"4'#&')9+%4$*4'$*'<4..>


B.2 CardiomyopathyB.2.1 Cost Inputs

Individual medication costs Price per tablet Goal regimen Annual cost

Furosemide 40 mg tablets $0.0029 40 mg 2x/d $2.08

Lisinopril 10 mg tablets $0.01 20 mg 1x/d $7.37

Carvedilol 25 mg tablets $0.035 25 mg 2x/d $25.6

Isosorbide dinitrate (IDN) 20 mg tablets

$0.025 20 mg 3x/d $27.2

Hydralazine 50 mg tablets $0.023 25 mg 3x/d $23.9

Spironolactone $0.020 25 mg 1x/d $7.3

B.2.2 Annual Regimen Costs Per PatientRegimen Annual cost

FLC: Furosemide 40 mg 2x/d, lisinopril 20 mg 1x/d, carvedilol 25 mg 2x/d

$40.25

FHIC: Furosemide 40 mg 2x/d, hydralazine 50 mg 3x/d, IDN 20 mg 3x/d, carvedilol 25 mg 2x/d

$90.46

t Prevalence given for the entire population.tt 300 cases per year.

Average annual cost

ConditionCase- finding rate

Population prevalence. Cases found Total Per patient Per capita

Cardiomyopathy 30% 0.2% 6,000 $2,009,506 $334 $0.20

Cardiac surgical follow-up

3% 0.1% 300 $3,709 $412 $0.012

Screening and follow-up for HIV nephropathy

100% 0.1% 9,000 $46,873 $5 $0.005

Diabetes 50% 0.44% 22,000 $3,806,655 $173 $0.38

Hypertension (160/90 threshold)

100% 4% 400,000 $7,632,542 $9 $0.76

Chronic respiratory disease

15% 2% 24,900 $1,453,695 $57 $0.14

Epilepsy 30% 1% 30,000 $738,003 $25 $0.07

Chronic care integration subtotal

$4,393,920 $1.57

Cardiac surgery (initial surgery)tt

3% 0.1% 300 $1,164,000 $3,880 $0.12

TOTAL $4,393,920 $1.69

appendix b | cost models 263

Other program costs (per patient) Annual cost

Laboratory testing (point-of-care chemistries @ $9.8 during 5 visits) $59

Transport (12 visits per year @ $3 per visit) $48

Community health workers (@ $30 per month divided over 5 patients) $72

NCD nurse (@ $10,000 base; 12 visits) $33

Marginal cost of hospitalization (5 days per year at $15 per day) $75

Subtotal $287

B.2.3 Population Age Distribution and Case-Finding (Catchment Area: 350,000)

Estimated cardiomyopathy prevalence 0.2%

Case-finding 30%

Total cardiomyopathy population 700

Total cardiomyopathy patients enrolled in program 210

B.2.4 Total Marginal Costs Per CapitaAnnual cost

Medication costs per patient (85% on FLC and 15% on FHIC) $47.8

Other program costs per patient $287

Total costs per patient $334

Marginal annual program cost $70,333

Marginal annual cost per capita $0.20

B.3 Cardiac SurgeryB.3.1 Cost InputsB.3.1.1 Follow-Up Cost Inputs

Medication Price per unit/tablet Goal regimen Annual cost

Warfarin 5 mg tablets $0.13 5 mg 1x/d $46

Warfarin 1 mg tablets $0.06 1 mg 1x/d $21

INR cartridge $3 16 test/yr $48

$0

$2,815

$5,630

$8,444

$11,259

50 100 150 200 250 300

Number of Surgeries per Year

average fixed cost/patient average variable cost/patient


B.3.1.2 Surgical Cost Inputs (At 300 Cases Per Year)Item Unit cost Number Total annual cost

Operating supplies $800 300 $240,000

ICU costs $500 300 $150,000

Hospitalization costs $600 300 $180,000

Mechanical valves (2 out of 3 cases) $1000 200 $200,000

Facility cost fixed fixed $50,000

Equipment depreciation annual fixed fixed $20,000

Surgeon salary $72,000 2 $144,000

Perfusionist salary $12,000 2 $24,000

Scrub nurse salary $9,000 2 $18,000

Circulating nurse salary $9,000 2 $18,000

Anesthesiologist salary $40,000 2 $80,000

ICU nurse salary $10,000 4 $40,000

Total surgical cost $1,164,000

Total surgical per patient cost $3,880

B.3.1.3 Average Cardiac Surgical Costs as a Function of the Number of Annual Operations

$*'#84'9":34%'&6'&-4%$#)&9*'-4%'74$%')9+%4$*4*>


B.3.1.4 Regimen and Follow-Up Costs

Visits per year Cost per visitAnnual cost per patient

INR cartridge 16 3 $48

Transport 16 3 $48

Echocardiography 2 72 $144

Community health worker N/A N/A $72

Warfarin 5 mg 1x/d N/A N/A $67

NCD nurse (@ $10,000 base), 12 visits

12 $2.78 $33.3

Subtotal $412

B.3.2 Population Age Distribution and Case-FindingPopulation of Rwanda 10,000,000

Estimated population prevalence of advanced RHD 0.1%

Total advanced RHD population in need of surgery 10,000

B.3.3 Total Marginal Costs Per Capita (At 300 Cases Per Year)Total surgical cost per patient cost $3,880

Total follow-up cost per patient per year $412.1

Marginal annual follow-up cost $160,439

Annual per capita cost $0.13

B.4 Screening for HIV NephropathyB.4.1 Cost Inputs

Medication or lab Price per unit Goal regimen Annual cost


Urine dipstick $0.02 N/A N/A

Creatinine $3 N/A N/A

B.4.2 Marginal Follow-Up CostsOther program costs (per patient enrolled) Annual cost

Laboratory testing (point-of-care chemistries @ $9.8 x 6 visits) $58.8


B.5 DiabetesB.5.1 Cost Inputs

MedicationPrice per unit/tablet Goal regimen

Units/tablets per day Annual cost

Insulin 70/30 (mixte)100 IU/mL, 10 mL

$0.009 15 U 2x/d 30 $99

Insulin regular (rapide)100 IU/mL, 10 mL

$0.010 10 U 2x/d 20 $72

Insulin NPH (lente)100 IU/mL, 10 mL

$0.010 15 U 2x/d 30 $109

Syringes(1 mL, 26 g needle)

$0.088 2x/d 2 $65

Metformin500 mg tablets

$0.010 1000 mg 2x/d 4 $15

Glibenclamide5 mg tablets

$0.003 5 mg 2x/d 2 $2

Lisinopril10 mg tablets

$0.01 5 mg 1x/d 0.5 $2

Total costs

Screening laboratory cost $1,057.88

Medication cost $580.62

Follow-up costs $58.8

Total annual program cost $1,697.30

Marginal per capita program cost $0.005

B.4.3 Population Age Distribution and Case-FindingTotal population size 350,000

HIV population prevalence (all ages) 2%

HIV proteinuria prevalence 6%

Total HIV+ population 5,250

Total with HIV and proteinuria 315

B.4.4 Total Marginal Costs Per CapitaCost to screen population Cost

Urine dipstick for screening population $112.88

Creatinine for patients with proteinuria $945

Total $1,057.9


Cost estimates Medications Clinic visits. Lab testing† FSBG‡ CHW salary Total annual cost

Oral $19 $18 $27 N/A N/A $64

Mixte insulin $165 $36 $30 $20 $87 $338

Lente insulin $176 $36 $30 $20 $87 $349

Lente + Regular insulin

$207 $36 $30 $20 $87 $380

Testing supply Units per package Package price Price per test

Finger-stick blood glucose N/A N/A $0.35

Creatinine N/A N/A $3

Urine dipstick 100 $2.2 $0.02

Point-of-care HbA1c 20 $177.2 $8.86

B.5.2 Annual Regimen Costs Per PatientRegimen Components

Oral Metformin 1000 mg 2x/d, Glibenclamide 5 mg 1x/d, Lisinopril 5 mg 1x/d

Mixte Mixte 70/30 15 Units 2x/d, Lisinopril 5 mg 1x/d

Lente Lente 15 Units 2x/d, Lisinopril 5 Units 1x/d

Lente + Regular Lente 10 Units 1x/d + Regular 10 Units 2x/d, Lisinopril 5 mg 1x/d

t Clinic cost: $3/visit. If on oral therapy: 6 visits/year. If on insulin: 12 visits/year.† Annual testing: finger-stick glucose at each visit; creatinine 2x/year, HbA1c 2x/year.‡ If on insulin, 56 finger-stick blood glucose (FSBG) in the community per year (2 FSBG per day x 7 days, done 4 times per year).

B.5.3 Population Age Distribution and Case-FindingTotal population of catchment area 350,000

Percent of population over age 20 years (adults) 44%

Prevalence of diabetes in adults 1%

Case-finding rate 50%

Adults in catchment area 154,000

Adults with diabetes 1540

Cases found 770


t H = HCTZ; N = amlodipine; L = lisinopril; A = atenolol

B.6 Hypertension Cost ModelsB.6.1 Cost Inputs

Medication Price per tablet Goal regimen Annual cost

HCTZ 25 mg tablets $0.003 25 mg 1x/d $1.03

Amlodipine 5 mg tablets $0.01 10 mg 1x/d $4.69


Atenolol 50 mg tablets $0.01 25 mg 1x/d $0.97

Methyldopa 250 mg tablets $0.02 500 mg 2x/d $33.6

Hydralazine 25 mg tablets $0.04 50 mg 3x/d $83.9

Labetalol 100 mg tablets $0.17 200 mg 2x/d $250.6

Nifedipine 10 mg tablets $0.01 20 mg 2x/d $19

Nifedipine retard 20 mg tablets $0.02 20 mg 2x/d $4.6

B.6.2 Annual Regimen Costs Per Patient.

Medication regimens Annual cost per patient

1. H: HCTZ 12.5 mg $0.59

2. HN: HCTZ 25 mg, amlodipine 10 mg $6.57

3. HNL: HCTZ 25 mg, amlodipine 10 mg, lisinopril 20 mg $16.04

4. HNLA: HCTZ 25 mg, amlodipine 10 mg, lisinopril 20 mg, atenolol 25 mg

$19.56

B.5.4 Total Marginal Costs Per CapitaTotal cost

RegimenProportion of patients on this regimen

Estimated patient load

Total annual cost

Oral 66% 505 $32,406

Lente insulin 13% 98 $34,315

Lente + Regular insulin 22% 167 $63,394

Total 770 $130,114

Annual Marginal Cost $0.37


B.6.3 Population Age Distribution and Case-FindingTotal population of catchment area (district) 100% 350,000

Percent of population over age 30 years (adults) 30% 105,000

Prevalence of stage I (>140/90) 7% 24,500

Prevalence of stage II (>160/100) 3% 10,500

Prevalence of stage III (>180/110) 1% 3,500

B.6.4 Total Marginal Costs Per Capita

Program costs by treatment threshold140/90

threshold160/100 threshold

180/110 threshold

Population at risk (# patients) 38,500 14,000 3,500

Total annual medication costs $143,356 $128,856 $59,837

Total annual clinic costs $199,500 $126,000 $63,000

Total laboratory costs $11,014 $6,812 $3,437

Total supply costst $5,471 $5,471 $5,471

Total costs $359,341 $267,139 $131,744

Average annual medication cost per patient

$3.72 $9.20 $17.10

Annual per capita medication cost $0.41 $0.37 $0.17

Marginal annual per capita total cost $1.03 $0.76 $0.38

t Automatic blood pressure machines (1 per 200 population @ $46.89 each).

t H = HCTZ; N = amlodipine; L = lisinopril; A = atenololtt Clinic cost: Stage I (1 visit per year); Stage II (2 visits per year); Stage III (6 visits per year). $3/visit

Hypertension stage Regimen.

Total clinic costs.. Medication

Laboratory testing Total costs

Stage I (140/90)

100% H $3 $0.59 $0.17 $3.7

Stage II ( 160/100)

100% HN $6 $6.57 $0.32 $12.9

Stage III ( 180/110)

70% HNL, 30% HNLA

$18 $17.10 $0.98 $36.1

Hypertension stage Projected yearly lab monitoringLaboratory costs per patient per year

Stage I (140/90) Urine dipstick 1x/y, creatinine 1x/y for 5%

$0.17

Stage II ( 160/100) Urine dipstick 1x/y, creatinine 1x/y for 10%

$0.32

Stage III ( 180/110) Urine dipstick 1x/y, creatinine 1x/y for 20%, chemistries 5%

$0.98


B.7.3 Population Age Distribution and Case-FindingTotal population of catchment area 350,000

Prevalence of chronic respiratory disease 2%


Total cases of chronic respiratory disease (in those over 5 years of age) 24,500

Cases found 871

t Including transportation cost.tt Includes community health worker e#ort for directly observed therapy.

Asthma severity MedicationsClinic visits

Cost per clinic visit

Total clinic visit cost

Total cost per patient

Intermittent $20 3 $3 $9 $29

Moderate persistent $53 10 $3 $30 $83

Severe persistent $79 12 $7* $83 $211tt

Severity classificationEstimated severity distribution Patients Total annual cost

Intermittent asthma 60% 523 $15,318

Moderate persistent 35% 305 $25,361

Severe persistent 5% 44 $9,213

Total 100% 490 $49,892

B.7 Chronic Respiratory Disease Cost ModelsB.7.1 Cost Inputs

Individual medication costsPrice per unit/tablet Goal regimen

Annual cost

Salbutamol 0.1 mg inhaler $0.01 200 mcg 4x/d $20

Beclomethasone 250 mcg inhaler, medium dose

$0.02 500 mcg 2x/d $33

Beclomethasone 250 mcg inhaler, high dose $0.02 750 mcg 2x/d $49

Aminophylline 100 mg tablets $0.00 200 mg 3x/d $10

B.7.2 Annual Regimen Costs Per PatientAsthma severity Regimen

Intermittent Salbutamol 200 mcg 4x/d

Moderate persistent Salbutamol 200 mcg 4x/d, beclomethasone 500 mcg 2x/d

Severe persistent Salbutamol 200 mcg 4x/d, beclomethasone 750 mcg 2x/d, aminophylline 200 mg 3x/d


B.8 Epilepsy Cost ModelsB.8.1 Cost Inputs

MedicationPrice per tablet/unit Goal regimen

Annual cost per patient

Carbamazepine 200 mg tablets $0.02 200 mg 2x/d $11.1

Phenytoin 100 mg tablets $0.01 150 mg 2x/d $6.1

Phenobarbital 100 mg tablets $0.01 100 mg 1x/d $2.11

Valproic acid 150 mg tablets $0.11 150 mg 3x/d $116.1

Valproic acid 500 mg tablets $0.34 500 mg 3x/d $370.9

B.7.4 Total Marginal Costs Per Capita

Severity classificationTotal annual medication cost

Total annual clinic costs Total CHW cost Total annual cost

Intermittent asthma $10,612 $4,706 - $15,318

Moderate persistent $16,210 $9,151 - $25,361

Severe persistent $3,461 $2,615 $3,137 $9,213

Total $30,283 $16,471 $3,137 $49,892

Annual cost per patient $35 $19 $4 $57

Marginal annual per capita cost $0.09 $0.05 $0.01 $0.14

B.8.2 Annual Regimen Costs Per Patient

RegimenAnnual regimen costs (per patient)

Annual clinic visits

Cost per clinic visit

Annual clinic visit cost

Total annual cost

Phenobarbital 100 mg 1x/d

$2.12 6 $3 $18 $20

Carbamazepine 100 mg 2x/d

$11.08 6 $3 $18 $29

B.8.3 Population Distribution and Case-FindingCatchment area 350,000

Epilepsy prevalence (generalized seizures) 0.5%

Epilepsy prevalence (partial seizures) 0.5%


Total population with generalized seizures 1750

Total population with partial seizures 1750

Total cases found 1050


B.8.4 Total Marginal Costs Per CapitaEstimated total marginal program cost $25,830

Estimated marginal per capita program cost $0.07

appendix cIndicators for Monitoring and Evaluation

C.1 Heart Failure and Post-Cardiac Surgery Follow-Up

Demographics

Percent male and female

Median age

Number of new patients enrolled during reporting period

Total number of patients at the end of reporting period

Total number of patients at the end of reporting period by district and sector

Diagnosis and Case-Finding

Number and percent of patients without a cardiology consultation since enrollment

Number and percent of patients without a preliminary echocardiogram, preliminary diagnosis or both

Number and percent of patients referred each quarter to NCD heart failure clinic and confirmed not to have heart failure

Percent of patients without a creatinine check in the last 6 months

Percent in each diagnostic category (cardiomyopathy, pure mitral stenosis, other rheumatic heart disease, pericardial disease, congenital heart disease)

Number/percent with creatinine 200 !mol/L

Number of post-cardiac surgery patients

Interventions

In the cardiomyopathy subgroup, percent with heart rate 60 bpm at last visit not on carvedilol

In the cardiomyopathy subgroup, percent on lisinopril or captopril

In the mitral stenosis subgroup, percent with heart rate 60 bpm at last visit not on atenolol

In the rheumatic heart disease subgroup, percent on penicillin

In the subgroup of women < 50 years old, percent using modern contraception

Case-Holding/Retention

Percent and number of patients not seen in the last 6 months


Percent and number of patients without a community health worker

Palliative Care

Percent and number of patients with reported pain score 0 or 1

Percent and number of patients with reported dyspnea score 0 or 1


Palliative Care (continued)

Percent and number of patients with improvement of pain score since the last reporting period

Percent and number of patients with improvement of dyspnea score since the last reporting period

Percent and number of patients prescribed morphine for symptom relief

Outcomes

Number and percent of patients enrolled in the heart failure program who died in the last reporting period

Of patients enrolled in the heart failure program, number of hospitalizations in the last reporting period

Of the patients with a mechanical replacement valve, the number and proportion whose INR has been between 2 and 4 the entire time since the last reporting period

Data Quality

Percent and number of patients without an intake form

appendix c | indicators for monitoring and evaluation 275

C.2 Cardiac Surgical Referral and Case Selection

Demographics


Median age





Total number of cases referred for cardiac surgery evaluation since the last reporting period

Of the cases referred, the number and percent confirmed to be surgical candidates

Of the cases confirmed to be surgical candidates, the number and percent who have single valve disease

Of the cases confirmed to be surgical candidates, the number and percent who have disease of 2 or more valves

Of the cases confirmed to be surgical candidates, the number and percent who are labeled as requiring surgery within 1 year

Interventions

Of the number of cases referred for cardiac surgery, the number and percent who receive valve replacement

Of the number of cases referred for cardiac surgery, the number and percent who receive valve repair


Of the patients on the cardiac surgery registry, the number and percent who have not seen a cardiologist in the last 12 months

Of the patients on the cardiac surgery registry, the number and percent who have not had a cardiologist echocardiogram in the last 12 months

Palliative Care






Outcomes

Number and percent of patients enrolled in the cardiac surgery program who died during the last reporting period

Data Quality

Percent and number of patients without a contact phone number


C.3 Renal Failure

Demographics


Median age





Percent and number of patients with documented proteinuria that have ever had a creatinine check

Percent and number of patients referred from HIV clinic that have HIV and proteinuria

Of those enrolled in the renal failure program, percent and number of patients with stage IV or V CKD (eGFR 15 ml/min)

Interventions

Percent and number of patients with proteinuria who are treated with lisinopril or captopril




Percent and number of patients without a community health worker

Palliative Care






Outcomes

Percent and number of patients with hyperkalemia (K 5.0 mEq/dL)

Percent and number of patients with renal failure who have blood pressure controlled ( 130/80 mmHg)

Data Quality



C.4 Diabetes

Demographics


Median age





Percent and number of patients referred each quarter to NCD diabetes clinic and confirmed not to have diabetes

Percent and number of patients referred to NCD diabetes clinic and confirmed to have diabetes based on (a) fasting glucose 126 mg/dL, (b) HbA1c 6.5%

Percent without an HbA1c in the past 6 months

Percent without a documented foot examination in the past 12 months

Percent with a documented eye examination in the past 2 years

Interventions

Percent on any insulin

Percent on NPH + regular insulin

Percent on NPH insulin alone

Percent on Mixte insulin

Percent on metformin

Percent on glibenclamide




In subgroup (on insulin) percent and number of patients without a community health worker

Palliative Care




Outcomes

Percent with HbA1c 8%

Percent and number with 3 or more hypoglycemic episodes in prior 3 months

Percent and number of patients hospitalized for diabetes


Outcomes (continued)

Number of deaths in patients enrolled in the diabetes program in the last year

Data Quality



C.5 Hypertension

Demographics


Median age





Of patients referred to NCD hypertension clinic, number/percent confirmed to have hypertension

Of patients with confirmed hypertension, number/percent with stage I HTN

Of patients with confirmed hypertension, number/percent with stage II HTN

Of patients with confirmed hypertension, number/percent with stage III HTN

Of patients with confirmed hypertension, number/percent with proteinuria

Of patients 40 years old, number/percent without a recorded creatinine

Of patients with stage III HTN (SBP 180 or DBP 110), number/percent without creatinine

Interventions

Number/percent of patients with proteinuria on ACE inhibitor (or have documented contraindication)

Of patients with Stage III hypertension, number/percent on 2 or more antihypertensives




Palliative Care


Outcomes

Percent and number of patients with last recorded BP 140/90

Number of deaths in patients enrolled in the hypertension program in the last year

Data Quality



C.6 Chronic Respiratory Disease

Demographics


Median age





Of patients referred to NCD respiratory clinic, the number/percent with confirmed chronic respiratory disease

Of patients enrolled in NCD respiratory clinic, number/percent with asthma/COPD

Of patients enrolled in NCD respiratory clinic, number/percent with brochiectasis

Of patients enrolled in NCD respiratory clinic, number/percent evaluated for tuberculosis with sputum analysis

Of patients referred for sputum analysis, the number/percent diagnosed with tuberculosis

Interventions

Of patients in NCD respiratory clinic, number/percent treated with salbutamol

Of patients in NCD respiratory clinic, number/percent treated with beclomethasone (any dose)

Of patients in NCD respiratory clinic, number/percent treated with aminophylline

Of patients in NCD respiratory clinic, number/percent treated with prednisone in the last 3 months


Of patients in NCD respiratory clinic, number/percent not seen in the last 6 months

Of patients in NCD respiratory clinic, number/percent of patients with moderate or severe persistent classification not seen in the last 3 months

Palliative Care






Outcomes

Of patients in NCD respiratory clinic, number/percent who have improvement of severity classification over the last 6 months


Outcomes (continued)

Of patients in NCD respiratory clinic, number/percent who have worsening of severity classification over the last 6 months

Of patients in NCD respiratory clinic, number/percent who have an “intermittent” classification

Data Quality

Percent and number without an intake form


C.7 Epilepsy

Demographics


Percent and number in age range ( 15, 15–24, 25–34, 35–44, 45–54, 55 or older)





In the subgroup (onset 20 years old), number and percent checked for HIV and RPR

Number and percent in each diagnostic category (GTC-primary, GTC-secondary, GTC-not specified, focal, other)

Of patients referred to epilepsy clinic, number and percent thought to not have epilepsy

Interventions

Of patients on ARVs, number and percent on valproic acid

Of patients on valproic acid, number and percent with AST and ALT checked in last 12 months.


Percent and number not seen in the last 6 months

Palliative Care




Outcomes

Percent and number of patients without seizure in the last 3 months (adults and children)

Percent and number of patients with 2 seizures in the last 3 months (adults and children)

Percent and number of enrolled patients hospitalized for epilepsy in the last 3 months (adults and children)

Data Quality

Percent and number without an intake form

appendix dForms

,4%4'<4'-%&@)54'$'*$:-.)9A'&6'#84'6&%:*'"*45'#&'6&..&<'9&92+&:2:"9)+$3.4'5)*4$*4*'V`S(*X'$#'5)*#%)+#'8&*-)#$.*'$95'84$.#8'+49#4%*'$#'G?,2*"--&%#45'*)#4*')9';<$95$>'L..'6&%:*'8$@4'3&#8'[%49+8'$95'U9A.)*8'#%$9*.$#)&9*>'H84*4'6&%:*'$%4'"*45'3&#8'6&%'+.)9)+$.'$95':&9)#&%)9A'$95'4@$."$#)&9'-"%-&*4*>'H847'8$@4'A&94'#8%&"A8':$97'74$%*'&6'%4@)*)&9'#8%&"A8')9-"#'6%&:'$..'&6'#84'`S('+.)9)+)$9*>'H84*4'6&%:*'$%4'579$:)+'$95'"95&"3#45.7'<)..'+&9#)9"4'#&'+8$9A4'$*'#84'+8%&9)+'+$%4')9#4A%$#)&9'*#%$#4A7'4E-$95*'9$#)&9$..7>

L..'6&%:*'$%4'49#4%45'4.4+#%&9)+$..7')9#&'$9'4.4+#%&9)+':45)+$.'%4+&%5>'

2+)$9*'#&'%4-&%#'&9'-%&A%$:')95)+#&%*'V*44'APPENDIX CX>

D.1 Intake Forms

U$+8'5)*4$*4'6&..&<45')9'#84'`S('&%')9#4A%$#45'+8%&9)+'+$%4'+.)9)+*'8$*'$'+&%%4*-&95)9A')9#$P4'6&%:>'H84*4'6&%:*'A494%$..7'#$P4'/0':)9"#4*'#&'+&:-.4#4>'H84%4')*'*&:4'@$%)$#)&9')9')9#$P4'6&%:'.49A#8'3$*45'&9'#84'+&:-.4E)#7'&6'#84'5)*4$*4>'?9#$P4'6&%:*'$%4':4$9#'#&'34'%4-4$#45'4@4%7'Z':&9#8*'#&'/'74$%>

,4%4'<4'A)@4'$9'4E$:-.4'&6'$9')9#$P4'6&%:'"*45'6&%'84$%#'6$)."%4'-$#)49#*')9'#84'5)*#%)+#'`S('+.)9)+*>

1. History of present illness

A. Patient referred from: acute clinic hospital other clinic other_________________

B. Chief complaint _________________

C. Duration of symptoms ___ days /months / years

D. Ever hospitalized for these symptoms? yes no

Total number of hospitalizations: ____

E. Has the patient had:

dyspnea on exertion? yes no

orthopnea? yes no

If yes, does the patient sleep sitting because of orthopnea? yes no

F. Ever treated by a traditional healer for these symptoms ? yes no

Diagnosis: poisoning other_________________

Treatment: purgative other _________________

Cost: _________________FRW

G. If female: Did the symptoms start around delivery? n/a

yes no

If a woman between 15–45 years old, does she use birth

control?

If no, why__________

n/a

yes no

H. Does the patient have:

a. chronic cough (more than 3 weeks)? yes no

If yes : productive hemoptysis

b. night sweats that soak clothing? yes no

c. a large weight loss? yes no

If yes, how much? _____ kg or clothing is looser

I. Does the patient smoke? yes no past

If yes : traditional modern pipe ____ cigarettes or pipes/ day

J. Does the patient drink alcohol? yes no past

If yes : traditional _____ liters/ day modern_____ bottles/ day

Document any other relevant history:


3. Past medical history

A. Has the patient ever had an HIV test ? yes no

If yes, result: positive negative Date of last test: ____/____/____

If positive: Last CD4:______ Date: ______/______/______

Enrolled in the IMB HIV program? yes no

B. Has the patient ever been treated for tuberculosis? yes no

If yes, how many times? _______________ In what year(s) ? _______________

C. Other history :

2. Previous outpatient medications

Is patient on cardiac medications at intake? yes no Never taken cardiac medications

Medication Dose Frequency Still taking?

furosemide ____ mg oral IV 1/d 2/d 3/d yes no

captopril

lisinopril ____ mg oral

1/d 2/d 3/d

yes no

aldactone ____ mg oral 1/d yes no

atenolol

carvedilol ____ mg oral

1/d 2/d

yes no

amlodipine

nifedipine ____ mg oral

1/d 2/d

yes no

digoxin ____ mg oral 1/d yes no

aspirin ____ mg oral 1/d yes no

warfarin ____ mg oral 1/d 2/d yes no

hydrochlorthiazide ____ mg oral 1/d yes no

methyldopa ____ mg oral 1/d 2/d 3/d yes no

isosorbide dinitrate

____ mg oral

1/d 2/d 3/d

yes no

hydralazine ____ mg oral 1/d 2/d 3/d yes no

prednisolone ____ mg oral 1/d 2/d yes no

penicillin V ____ mg oral 1/d 2/d 3/d yes no

benzathine penicillin 600,000 IU IM

1.2 M IU IM 1x/month 2x/month

yes no

______________ ____ mg oral IV 1/d 2/d 3/d yes no

Drug allergies ___________ yes no If yes, explain:_________________________

appendix d | forms 285

4. Social history

A. Occupation: unemployed retired farmer small child (< 5)

professional driver cleaner in school

school-aged,

not in school miner ____________

B. Too sick to work ? yes no

C. Civil status: married or lives with partner partner in prison

single or child divorced or separated

widow (partner died of:_________) orphan

D. Transport : foot bus bike taxi other

Cost of transport (round-trip)

Time to travel to health center

_______ FRW

_______ hrs

E. Socio-economic status:

The patient’s house has: _____ rooms _____ occupants

Does the patient’s family own a house? yes no

Roof is: tin thatch cement sheeting

The floor is: cement dirt

Does the patient’s family own land? yes no if yes: _________ hectares

Does the patient’s family have goats or cows? ______________ goats

__________ cows

How many children has the patient had or if a child, how many

siblings in the family? _____________________ children

Are all the children still alive? yes no

causes of death:________

Do all the school-aged children go to school? yes no N/A

Other social information:

5. Physical Exam

Vital signs:

BP: ______/_____ mmHg Pulse:_____ bpm Weight ______ kg Height ______ cm

Does the patient feel dizzy upon standing up? yes no

If indicated : RR: ______ SaO2: ____%

Normal Abnormal

General well-appearing

cachectic obese tachypneic

use of accessory muscles

HEENT JVP normal JVP high goiter

Lungs clear crackles (If yes, location:_________) wheezing

Heart PMI non-displaced

regular rhythm

no murmurs

tachycardia irregular rhythm PMI displaced

murmur 1 location :___________________________

systolic diastolic

murmur 2 location :___________________________

systolic diastolic

Abdomen soft non-tender

no hepatomegaly

no splenomegaly

no ascites

splenomegaly ____ cm hepatomegaly : ____ cm

pulsatile liver

ascites: mild moderate abundant

tenderness: RUQ LUQ RLQ LLQ

Extremities no peripheral edema

no joint pain or swelling

cold peripheral edema 1+ 2+ 3+

joints swollen joints

Neuro no abnormalities focal motor deficit

Other ___________________ ____________________________________________


6. Previous labs (including today)

Date Results

1. ___/___/___

2. ___/___/___

3. ___/___/___

Chemistries point of care

Na: K: Cal: iCa : CO2: Urée: Créat: Glyc: Hgb:

4. ___/___/___

INR/ PT point of care

INR : PT :

7. Previous studies

Date Results

CXR __/__/__

normal

cardiomegaly

mild moderate

severe

Infiltrates (location:____________)

pleural effusions small big

(location:__________________)

EKG __/__/__ normal LVH atrial fibrillation infarction (location:_______________)

8. Preliminary echocardiographic result:

Left ventricular function

Normal mildly depressed markedly depressed

Ejection fraction estimate:_________ %

No mitral stenosis Mitral stenosis

Normal right ventricular size Large right ventricle

Normal IVC Large IVC

Other abnormalities ____________________________________________________________

9. Clinical Impression

A. Summary

B. Diagnosis

Heart Failure

Type of Heart Failure:

Cardiomyopathy

Rheumatic heart disease Mitral stenosis Other

Hypertensive heart disease

Other type of Heart Failure: ____________________________________

Severity of symptoms (If between categories, mark both)

NYHA class I (Asymptomatic) No limitation on activity

NYHA class I-II NYHA class II (Mildly symptomatic)

Symptoms only with moderate exertion, such as climbing a hill

NYHA class II-III

NYHA class III (Moderately symptomatic)

Symptoms with even light activity but comfortable at rest

NYHA class III-IV

NYHA class IV (Severely symptomatic)

Symptoms with all activities, may be symptomatic at rest

Renal Failure

Liver Failure

Other

C. Patient’s fluid status: hypervolemic euvolemic hypovolemic


10. Final plan

A. Labs, studies: VS HIV sputum x 3 Chest X-ray _____________________

Albumin SGOT SGPT

B. Medications

No medications MORNING NOON EVENING

Furosemide (Lasix) ____ mg ____ mg

Captopril ____ mg ____ mg ____ mg

Lisinopril ____ mg ____ mg

Aldactone ____ mg ____ mg

Carvedilol ____ mg ____ mg

Atenolol ____ mg ____ mg

Amlodipine ____ mg ____ mg

Nifedipine retard ____ mg ____ mg

Isosorbide dinitrate ____ mg ____ mg ____ mg

Hydralazine ____ mg ____ mg ____ mg

Hydrochlorothiazide ____ mg

Potassium (600 mg tab =

8mEq) ____ mg ____ mg

Prednisolone ____ mg ____ mg

Aspirin ____ mg

Warfarin ____ mg

Penicillin V ____ mg ____ mg

Benzathine penicillin

600,000 UI IM 1x/month 2x/month

Benzathine penicillin

1.2 M UI IM 1x/month 2x/month

C. Other medications: _____________________

D. Disposition Admit to hospital Discharge home

Follow-up ____/____/____


EMR CLINIC Rwinkwavu Kirehe Butaro

Other:______________________________________

Change in clinic yes Date: ___/___/___ Clinic______________________________________________

EMR DEMOGRAPHICS EMR ADDRESS

Date of birth:___/___/___ Province: _____________

Age: District : _____________

Sex F M Secteur: _____________

Daily CHW: yes not indicated

Name : _______________________________

Cellule: _____________

Umudugudu: _____________

Change in CHW yes

Name :_________________ Date: ___/___/___

Telephone: _____________

patient other___________

If a child: Name of parent or guardian

______________________________

Change in address or

telephone: yes

Date: ___/___/___

Go to page 2 to change Telephone:_____________________________

CARDIAC DIAGNOSIS

Diagnosis or Problem EF

Date of

dx Type Clinician

__/__/__ preliminary

confirmed

__/__/__ preliminary

confirmed

NON-CARDIAC DIAGNOSIS AND PROBLEM LIST

EMR Diagnosis Date EMR Diagnosis Date

__/__/__ __/__/__

__/__/__ __/__/__

__/__/__ __/__/__

Cardiology consultation completed _____/_____/_____

Surgical candidate? yes no

If yes: Passport : yes not indicated

Visa : yes not indicated


D.2 Flowsheets

<8).4':)9):)^)9A'-$-4%<&%P'$95'$..&<)9A'+.)9)+)$9*'#&'4$*).7'$**4**'$'

8$*'$'+&@4%'*844#'<)#8'*"::$%7'$95'54:&A%$-8)+')96&%:$#)&9'#8$#')*'-.$+45'$#'#84'6%&9#'&6'#84'+8$%#>

D.2.1 Sample Cover Sheet

HOSPITALIZATIONS

EMR

Date of

admission

Date of

discharge Hospital Reason for hospitalization

___/___/___ ___/___/___

___/___/___ ___/___/___

___/___/___ ___/___/___

SOCIAL ASSISTANCE OR ASSESSMENT

EMR Date

Type of assistance or

assessment EMR Date

Type of assistance or

assessment

___/___/___ ___/___/___

___/___/___ ___/___/___

___/___/___ ___/___/___

(ex. Home visit, house construction, school financing, transport financing, food supplementation)

CHANGE IN CHW, ADDRESS OR TELEPHONE

EMR Date

___/___/___

___/___/___

___/___/___

NON-MEDICAL LIFE EVENTS SINCE DIAGNOSIS

EMR Date Event EMR Date Event

___/___/___ ___/___/___

___/___/___ ___/___/___

___/___/___ ___/___/___

(e.g. marriage, divorce, pregnancy, births, death of family members, change in socioeconomic status,

change in residence since diagnosis)


D.2.2 Sample Events Flowsheet

RENDEZ-VOUS/ CLINIC VISIT

Date Wt BP P

NYHA

Class Hemodyn.

Missed any

meds ? Na K CO2 Cr Hgb INR

On birth

control ? F/up

2/2/10

50

90/

60 110 III

X hyper

eu

hypo

X yes

no

N/A 133 4 24 130 11 N/A

yes

X no

N/A 2/9/10

Comments :

2/9/10

45

100/

70 80 II

hyper

X eu

hypo

X yes

no

N/A

X yes

no

N/A 2/16/10

Comments :

CLINIC VISITS

Date

# times/week

awoken by

dyspnea

# puffs/week

of salbutamol

Peak

Flow

Good

inhaler

technique

Asthma

classification

not asthma

Activity

limitation due

to shortness of

breath Plan and Follow-up

_______ times _______ puffs

yes

no

brief

coaching

given

well-

controlled

moderately

controlled

poorly

controlled

daily or

almost daily

several times

per week

less than

once per week

not at all

RDV ___/___/___

group class :

___/___/___

step up treatment

continue the same

treatment

step down

treatment Comment :

CLINIC VISITS

Date Weight BP Pulse Proteinuria Na K CO2 Cr Missed insulin ?

yes no N/A

Glucose: Glucose today :___________________ fasting

Sx of low blood

sugar ? yes no When?: morning afternoon evening

Comments


D.2.3 Clinical Findings Flowsheet,4%4')*'$9'4E$:-.4'&6'8&<'#<&'%&<*'6%&:'#84'+.)9)+$.')95)+$#&%*'-$A4':)A8#'.&&P'6&%'$'#7-)+$.'84$%#'6$)."%4'-$#)49#>',4%4C'<4'*44'#84'-$#)49#'

@)*)#')9'#84'*4##)9A'&6':)**)9A'84%':45)+$#)&9*>'L'-&)9#2&62+$%4'+84:)*#%7'-$94.'<$*'5&94>'H84'-$#)49#'<$*'$.*&'9&#'&9'3)%#8'+&9#%&.>'b9'#84'94E#'@)*)#C')#')*'+.4$%'#8$#'#84'-$#)49#=*'@)#$.'*)A9*'$95'*7:-#&:'+.$**'):-%&@45'$95'*84'8$5'3449'#$P)9A'84%':45)+$#)&9*>'Y84'$.*&'8$5'3449'*#$%#45'&9'3)%#8'+&9#%&.>

6&%'*&:4'&6'#84'&#84%'5)*4$*4*'6&..&<45')9'#84'+.)9)+*>

D.2.3.1 Asthma

D.2.3.2 Diabetes

CLINIC VISIT

Date Wt BP P

NYHA

Class

Volume

Status

Missed

any

meds ? Na K Cr Hgb INR

On birth

control ? F/up

hyper

eu

hypo

yes

no

NA

yes

no

NA

Comments :

CLINIC VISIT

Date Weight BP Pulse Proteinuria Na K Cr F/up

Comments

MEDICATION LIST

Medication Dose Frequency Start date

Stop

date Reason for stopping

__/__/__ __/__/__

__/__/__ __/__/__

__/__/__ __/__/__

__/__/__ __/__/__

CLINIC VISIT

EMR Date

Number of

seizures

Missed

medications

Side effects If female: Plan

__/__/__

_________ seizures

None

Only with illness,

alcohol

yes

no

yes

no

On birth control:

yes no

Pregnant

No change

Change in médications

Labo/Labs EEG CTAllaitement/nursing

yes no

Comments:

RDV __/__/__

Clinicians


D.2.3.3 Post-Cardiac Surgery

D.2.3.4 Hypertension

D.2.3.6 Medication Flowsheet

+.)9)+$.')95)+$#&%*'*844#C'#8)*'$..&<*'+.)9)+)$9*'#&'*44'$#'$'A.$9+4'3&#8'<8)+8':45)+$#)&9*'#84'-$#)49#')*'&9'$95'<8$#'+8$9A4*'8$@4'3449':$54'%4+49#.7>'H8)*')*'-$%#)+".$%.7'84.-6".'6&%'6&..&<)9A'-$#)49#*'<)#8'5)*4$*4*'*"+8'$*'84$%#'6$)."%4C'<8)+8'%4O")%4'6%4O"49#'5&*4'$5D"*#:49#*>

D.2.3.5 Epilepsy

ASSESSMENT OF SYMPTOM MANAGEMENT (To be done at intake and as needed thereafter)

Ask the following questions with regard to the last 3 days

Have the patient rate their answer on a scale of 0 (none or not at all) to 5 (a lot or all the time).

Date __/__/__ __/__/__ __/__/__ __/__/__

1. Rate your pain

2a. Have any other symptoms been affecting how you

feel?

2b. If so, please rate each symptom:

Dyspnea

Nausea or vomiting

Constipation

Diarrhea

Incontinence

Pruritus

Fever

Weakness

Insomnia

Foul Odor

3. Have you been feeling worried about your illness?

4. Have you been able to share how you are feeling

with your family or friends?

5. Have you felt life was worthwhile?

6. Have you felt at peace?

7. Have you had enough help and advice for your

family to plan for the future?

If family is present:

8. How much information have you and your family

been given?

9. How confident has the family felt caring for the

patient?

10. Has the family been feeling worried about the

patient?


D.2.4 Palliative Care Flowsheet

&"#'$#'#84'5)*+%4#)&9'&6'#84'+.)9)+)$9C'54-495)9A'&9'#84'*4@4%)#7'&6'#84'-$#)49#=*'5)*4$*4>'H84'O"4*#)&9*'$%4'3$*45'&9'#84'L6%)+$9'G$..)$#)@4'S$%4'L**&+$#)&9=*'G$..)$#)@4'S$%4'b"#+&:4*'*+$.4C'<8)+8'8$*'3449'@$.)5$#45')9'%"%$.'*"32Y$8$%$9'L6%)+$9'+&::"9)#)4*>/


Appendix D!References

/' ,$%5)9A';C'Y4.:$9'FC'LA"-)&'TC'4#'$.>'\$.)5$#)&9'&6'$'+&%4'&"#+&:4':4$*"%4'6&%'-$..)$#)@4'+$%4')9'L6%)+$W'#84'LGSL'L6%)+$9'-$..)$#)@4'&"#+&:4'*+$.4>',4$.#8's"$.'F)64'b"#+&:4*'J1/1hgW/1>

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the pih guide to


rwanda edition

the pih guide toChronic Care Integration for Endem

ic Non-Com

municable D

iseasesrw

anda edition

Partners In Health



Partners In Health is a 501(c)3 nonprofit corporation based in Boston, Massachusetts. Established in 1987, PIH is committed to making a preferential option for the poor by working with sister organizations to improve the health and well-being of people living in poor communities. To this end, PIH provides technical and financial assistance, medical supplies, and administrative support to partner projects in Haiti, Peru, Russia, Rwanda, Lesotho, Malawi, Mexico, Guatemala, Burundi, Kazakhstan, the Dominican Republic, and the United States. The goal of these partnerships is neither charity nor development but rather “pragmatic solidarity”— a commitment to struggle alongside the destitute sick and against the economic and political structures that cause and perpetuate poverty and ill health. Partners In Health is a!liated with the Division of Social Medicine at Harvard Medical School and the Division of Global Health Equity at the Brigham and Women’s Hospital.

More information on Partners In Health can be found at our web site: www.pih.org

chronic care integration for endemic ncds.pdf - ncd alliance

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