heart failure, hypertension with type 2 diabetes mellitus
TRANSCRIPT
HEART FAILURE, HYPERTENSION with TYPE 2 DIABETES MELLITUS
Heart Failure
Pathophysiology
Compensatory mechanisms
• Tachycardia & SNS +• Frank starling Mechanism
(Increase in preload – Increase in stroke volume)
• Vasoconstriction• Ventricular Hypertrophy &
remodeling
Neurohormonal Mechanisms
• Angiotensin II (Production in heart from non- ACE dependent pathways)
• Nor Epinephrine• Natriuretic peptide (A-NP, B-
NP, C-NP)• Aldosterone (Interstitial
cardiac fibrosis)• Arginine Vasopressin
(Released from Pituitary and acts on V1a & V2 Receptors)
• Age: 55 years• Sex: Female• Weight: 67 Kg• Unit: Med 4• IP No: 283747
• Reasons for admission: C/O breathlessness and wheezing since 2 days H/O excessive breathlessness more during
activity since 2 days and is progressive in nature from grade 2 to grade 4.
H/O cough since 1 week.• PMHx: k/c/o HTN and T2DM since 20 years and on
regular treatment Enalapril 2.5 mg 1-0-0 and insulin
This patient belongs to Stage C (lllb) of Heart Failure
No Hx of TB/ Thyroid/ Cardiac disease
• Allergies: NKA
• SHx: NS
General examination
• NO Pallor/ Icterus/ Clubbing/ Edema/ Cyanosis• BP: 160/90 mmHg• Pulse: 80 BPM• CVS: S1S2 +, Tachycardia +, No murmurs• RS: B/L NVBS +, Tachypnoea +• CNS: NFND• SpO2: 95%
PROVISIONAL DIAGNOSIS
T2DM with HTN with CCF to R/O IHD ? Dilated Cardiomyopathy
CARDIOMYOPATHY• Dilated Cardiomyopathy (DCM) CAD, MI, Infections, Alcohol,
Cocaine, Amphetamines, Doxorubicin
• Hypertrophic Cardiomyopathy (HCM)Mostly inherited, Persistent hypertension, Diabetes, Thyroid disorders
• Restrictive Cardiomyopathy (RCM)Hemochromatosis, sarcoidosis, Amyloidosis, Connective tissue disorders.
DAY1
• BP: 160/90 mmHg Pulse: 80 BPM• CVS: S1S2 +, Tachycardia +, No murmurs• RS: B/L NVBS +, Tachypnoea +• CNS: NFND• SpO2: 95%
DAY 1 cont…
• ADV: HCT, RBS, FBS, PPBS, HbA1C, Urea, Serum Creatinine, Serum electrolytes, Urine routine, ECG, 2D-ECHO, CXR- PA view, Fundoscopy.
LAB REPORTSHematology
Hb:WBC:DLC:•N•E•B•L•MPlt:ESR:
10 g%7400 cells/ cumm
68%01%00%30%01%3.85 lakhs cells/ cumm120 mm/hr
RBSUREAS.Cr
177 mg/dl90 mg/dl1.5 mg/dl
Electrolytes
SodiumPotassiumChlorides
139 mmol/ L4.4 mmol/ L100 mmol /L
TREATMENT CHARTDrug Dose R Freq. D
1
Inj. Furosemide 40 mg IV 1-1-0 +
Inj. Insugen – R 4-4-4 SC 1-1-1 +
Tab. Pantoprazole 40 mg PO 1-0-0 +
Syp. Viscofast (Bromohexine + Terbutaline + Guanephensin)
5 ml PO Q8H +
Inh. Levosalbutamol + Ipratropium Br 100 mcg + 20 mcg
INH Q8H +
Tab. Telmesartan 40 mg PO 1-0-0 +
Inj. Piperacillin Tazobactum 4.5 g IV 1-1-1 +
DAY 2
• BP: 130/70 mmHg Pulse: 80 BPM• O/E patient was symptomatically better• C/O Numbness B/L feet (DPN)• HbA1C: 8.6 FCBG: 141 mg/dl• SpO2: 96%• CVS: S1S2 +, no Murmurs• RS: B/L NVBS +
DIABETIC PERIPHERAL NEUROPATHY
DAY 2 cont…
• ADV: 2D- ECHO, Thyroid Profile, Ophthalmologist, Treatment as per chart
• Ophthalmologist opinion: Moderate DR+ (NPDR)
CXR - PA view showing NORMAL and CARDIAC HYPERTROPHY
21
Fundoscopic differences Between Hypertensive & Diabetic Retinopathy
Hypertensive Retinopathy Diabetic Retinopathy
Retina Dry Wet
Hemorrhages Few Multiple
Edema Rare Extensive
Exudates Rare Multiple
Cotton wool spots Multiple Few
Flame shaped Hemorrhages
Common Rare
Visually abnormal blood vessels in retina
Arteries Veins
TREATMENT CHARTDrug Dose R Freq. D
1 D2
Inj. Furosemide 40 mg IV 1-1-0 + +
Inj. Insugen – R 4-4-4 SC 1-1-1 + +
Tab. Pantoprazole 40 mg PO 1-0-0 + +
Syp. Viscofast (Bromohexine + Terbutaline + Guanephensin)
5 ml PO Q8H + +
Inh. Levosalbutamol + Ipratropium Br 100 mcg + 20 mcg
INH Q8H + +
Tab. Telmesartan 40 mg PO 1-0-0 + +
Inj. Piperacillin Tazobactum 4.5 g IV 1-1-1 + +
DAY 3
• BP: 130/80mmHg Pulse: 84 BPM• CVS: S1S2 +, no Murmurs• RS: B/L NVBS +• ADV: Treatment as per chart
TREATMENT CHARTDrug Dose R Freq. D
1 D2
D3
Inj. Furosemide 40 mg IV 1-1-0 + + +
Inj. Insugen – R 6-6-6 SC 1-1-1 + + +
Tab. Pantoprazole 40 mg PO 1-0-0 + + +
Syp. Viscofast (Bromohexine + Terbutaline + Guanephensin)
5 ml PO Q8H + + +
Inh. Levosalbutamol + Ipratropium Br 100 mcg + 20 mcg
INH Q8H + + +
Tab. Telmesartan 40 mg PO 1-0-0 + + +
Inj. Piperacillin Tazobactum 4.5 g IV 1-1-1 + + +
DAY 4
• BP: 130/90mmHg Pulse: 82 BPM• CVS: S1S2 +, no Murmurs• RS: B/L NVBS +, crepts +• CBG: 217 mg/dl FCBG: 194 mg/dl• Urea: 90 mg/dl S.Cr: 1.5 mg/dl• ECG imp: Left ventricular hypertrophy• ADV: Repeat urea, Creatinine, ECHO, Urine
Routine
TREATMENT CHARTDrug Dose R Freq. D
1 D2
D3
D4
Inj. Furosemide 40 mg IV 1-1-0 + + + +
Inj. Insugen – R 6-6-6 SC 1-1-1 + + + +
Tab. Pantoprazole 40 mg PO 1-0-0 + + + +
Syp. Viscofast (Bromohexine + Terbutaline + Guanephensin)
5 ml PO Q8H + + + +
Inh. Levosalbutamol + Ipratropium Br 100 mcg + 20 mcg
INH Q8H + + + +
Tab. Telmesartan 40 mg PO 1-0-0 + + + +
Inj. Piperacillin Tazobactum 4.5 g IV 1-1-1 + + + +
DAY 5
• BP: 136/80 mmHg Pulse: 76 BPM• Urea: 96 mg/dl S.Cr: 1.8 mg/dl• FCBG: 198 mg/dl PPBS: 232 mg/dl• O/E Patient symptomatically better• Thyroid Profile: WNL• ADV: CST, Nephrologists opinion
TREATMENT CHARTDrug Dose R Freq. D
1 D2
D3
D4
D5
Inj. Furosemide 40 mg IV 1-1-0 + + + + +
Inj. Insugen – R 10-10-0 SC 1-1-0 + + + + +
Tab. Pantoprazole 40 mg PO 1-0-0 + + + + +
Syp. Viscofast (Bromohexine + Terbutaline + Guanephensin)
5 ml PO Q8H + + + + +
Inh. Levosalbutamol + Ipratropium Br 100 mcg + 20 mcg
INH Q8H + + + + +
Tab. Telmesartan 40 mg PO 1-0-0 + + + + +
Inj. Piperacillin Tazobactum 4.5 g IV 1-1-1 + + + + +
Inj. H. Mixtard 0-0-16 SC 0-0-1 +
DAY 6
• BP: 174/76 mmHg Pulse: 85 BPM
• CVS: S1S2 +, no Murmurs• RS: B/L NVBS +• Patient discharged at request, will be followed
in Nephrology OPD
ECHO: Concentric LVH LV Diastolic Dysfunction EF: 74%
TREATMENT CHARTDrug Dose R Freq. D
1 D2
D3
D4
D5
D6
Inj. Furosemide 40 mg IV 1-1-0 + + + + + +
Inj. Insugen – R 10-10-0 SC 1-1-0 + + + + + +
Tab. Pantoprazole 40 mg PO 1-0-0 + + + + + +
Syp. Viscofast (Bromohexine + Terbutaline + Guanephensin)
5 ml PO Q8H + + + + + +
Inh. Levosalbutamol + Ipratropium Br 100 mcg + 20 mcg
INH Q8H + + + + + +
Tab. Telmesartan 40 mg PO 1-0-0 + + + + + +
Inj. Piperacillin Tazobactum 4.5 g IV 1-1-1 + + + + + +
Inj. H. Mixtard 0-0-16 SC 0-0-1 + +
Discharge medicationsDrug Dose R Freq.
Tab. Furosemide 40 mg PO 1-1-0
Inj. Insugen – R 10-10-10 SC 1-1-1
Inh. Levosalbutamol + Ipratropium Br 100 mcg + 20 mcg
INH Q8H
Tab. Telmesartan 40 mg PO 1-0-0
Inj. H. Mixtard 0-0-16 SC 0-0-1
Tab. Atorvastatin 10 mg PO 0-0-1
Tab. Amlodipine 5 mg PO 1-0-0
Pharmaceutical Care Plan
Subjective Evidence Objective Evidence
• Breathlessness • Wheezing• Orthopnoea• Cough
•ECG•ECHO•Blood Pressure•Elevated blood glucose •S.Cr levels•Urea levels
Final Diagnosis
Based on subjective and objective evidence the patient was diagnosed with T2- DIABETES
MELLITUS with HYPERTENSION with HEART FAILURE (Hypertrophic Cardiomyopathy –
Preserved Ejection Fraction) with CHRONIC KIDNEY DISEASE
Goals of Treatment For Heart Failure:
• Relieve symptoms of central and peripheral circulatory congestion
• Improve quality of life • Reduce neurohormonal
activation • Minimize or prevent acute
CHF exacerbations • Slow progression of CHF • Increase survival • Maintain appropriate blood
pressure and lipid values. • Reduce mortality
For Diabetes mellitus:• focus on controlling blood sugar levels
in the normal or near-normal range• Prevent symptoms of hyperglycemia• Promote SMBG • Administer medical and nutritional
therapy that balances food intake with physical activity and pharmacologic therapies
• Prevent long-term complications (micro vascular and macro vascular disease)
• Maintain appropriate blood pressure and lipid values.
• Treat other physiologic derangements when present.
• Maintain a flexible and normal lifestyle
Treatment Options
For Heart Failure• ACE inhibitors / ARB’s• Diuretics• Beta blockers• Spironolactone • Digoxin / Dopamine
For Diabetes:• Insulin• OHA1. Sulfonylurea's2. Biguanides3. Thiazolidinediones4. Alfa glucosidase
Inhibitors5. DPP- 4 inhibitors
Goals achieved
• Patient was symptomatically better by day 2• Blood pressure was brought to near normal by
day 3
Problems identified
• Cardiac enzymes were not done (CKMB)
Monitoring ParametersDisease Related
• ECG• ECHO• Chest X-ray• Blood pressure• Weight • Fluid intake• Electrolytes • Vital signs • Renal function test• Blood Glucose levels• Glycosylated Hb• Lipid Levels• Fundoscopy
Drugs Related• Blood Pressure• Blood Glucose levels• Weight• Electrolytes• Renal function test
Patient Counseling
About Disease
About Medication– Name and purpose
– Dose and frequency
– Medication adherence
– Possible adverse effects
– Missed dose
DASH Diet• Cut the Salt• Get Your Grains• Load Your Plate With
Vegetables• Don't Forget Fruit• Have Some Yogurt• Go for Lean Meats and Fish• Add Nuts and Legumes• Cut Back on Fats and Oils• Watch the Sweets• Get Enough Potassium
• Healthy life style with daily exercise
(the ADA recommends 150 min/week (distributed over at least 3 days) of aerobic physical activity)
• Self-Monitoring of Blood Glucose
• Nutritional recommendations
Food/amount Serving/exchange The size of
1 cup cooked rice or pasta 2 starch tennis ball
1 slice bread 1 starch compact disc case
1 cup raw vegetables or fruit 1 fruit or vegetable baseball
1/2 cup cooked vegetables or fruit 1 fruit or vegetable cupcake wrapper full or size of ice cream scoop
1 ounce cheese 1 high-fat protein pair of dice
1 teaspoon olive oil 1 fat** half dollar
3 ounces cooked meat 1 protein deck of cards
3 ounces tofu 1 protein deck of cards
** Remember to count fat servings that may be added to food while cooking (oil for sautéing, butter, or shortening for baking)
THANK YOU