Case Study Chief Complaint: I'm Here For A Medication Refill

Case Study chief Complaint: “I’m here for a medication refill because I

Mrs. Allen, a 68-year-old African American woman, presents with symptoms indicative of congestive heart failure (CHF) and a history of cardiovascular disease, including prior myocardial infarction (MI). Her clinical picture includes exertional and orthopneic shortness of breath, lower extremity edema, and episodes of lightheadedness and syncope. Her physical examination reveals findings consistent with volume overload and cardiac dysfunction, including bilateral pitting edema, S4 gallop, and a systolic murmur. Laboratory and imaging results, notably a decreased ejection fraction (EF) of 35% and an elevated BNP, support a diagnosis of systolic heart failure. She has significant comorbidities, including hypertension, obesity, osteoarthritis, and a family history of cardiac disease, which compound her cardiovascular risk profile. The management involves pharmacotherapies aligned with the American College of Cardiology/American Heart Association (ACC/AHA) guidelines for CHF and secondary prevention of ASCVD, considering her prior MI and current clinical status.

Paper For Above instruction

In managing Mrs. Allen’s congestive heart failure (CHF), medication therapy should adhere to the guidelines established by the American College of Cardiology (ACC) and the American Heart Association (AHA). These guidelines emphasize the importance of evidence-based pharmacotherapies tailored to reduce mortality, improve symptoms, and prevent disease progression in systolic heart failure (Yancy et al., 2017).

Pharmacologic Management of Congestive Heart Failure

The cornerstone medications for systolic heart failure, particularly in patients with reduced ejection fraction (HFrEF), include angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), beta-blockers, mineralocorticoid receptor antagonists (MRAs), and in some cases, neprilysin inhibitors. For Mrs. Allen, prescribing an ACEI such as lisinopril or an ARB like losartan would be appropriate to inhibit the maladaptive renin-angiotensin-aldosterone system (RAAS), reduce preload and afterload, and improve survival (McMurray et al., 2014). Since she has a history of MI and reduced EF, an ACEI or ARB is essential in her regimen.

Adding a beta-blocker such as carvedilol, metoprolol succinate, or bisoprolol is crucial as these agents have been shown to decrease mortality and hospitalization. Initiation should be cautious, especially considering her hypotension and bradycardia risk, and titration should be gradual (Yancy et al., 2017). Given her symptoms of volume overload, diuretics such as furosemide may be used for symptom relief, but they do not impact mortality. Additionally, since her BNP is elevated indicating volume overload, optimizing diuretic therapy is essential.

Medications for Secondary Prevention of ASCVD

Mrs. Allen’s history of MI and existing ASCVD warrants aggressive secondary prevention. Statins are fundamental, with high-intensity formulations like atorvastatin 40-80 mg or rosuvastatin 20-40 mg recommended to lower LDL cholesterol effectively and reduce the risk of recurrent cardiovascular events (Stone et al., 2014). Her current LDL of 190 mg/dL signifies the need for intensive lipid-lowering therapy.

In addition, low-dose aspirin (81 mg daily) can be employed unless contraindicated, as it helps prevent thrombotic events post-MI (O’Gara et al., 2013). Blood pressure control remains an essential component; her current hypertensive state (BP 160/92) requires titration of antihypertensive medications, possibly including ACEIs or ARBs, to achieve target pressures (

Special Considerations for Pharmacotherapy

Given her history and current presentation, aldosterone antagonists such as spironolactone or eplerenone should be considered, especially in patients with NYHA class II-IV symptoms and elevated BNP, as these agents improve mortality and reduce hospitalization (Pitt et al., 2014). Monitoring her renal function and serum potassium is necessary to mitigate hyperkalemia risk.

Regarding her psychosocial and economic barriers, the choice of medications should consider affordability and adherence potential. Using generic formulations and simplifying regimens can improve compliance. Additionally, close follow-up and patient education about the importance of medication adherence and lifestyle modifications are vital in managing her chronic conditions.

Conclusion

In summary, Mrs. Allen requires a comprehensive pharmacologic approach targeting her systolic heart failure and secondary prevention of ASCVD. Initiating an ACE inhibitor or ARB, beta-blocker, and mineralocorticoid receptor antagonist aligns with ACC/AHA guidelines. These, combined with statin therapy and lifestyle modifications, can enhance her quality of life and reduce mortality risks. Careful monitoring for adverse effects, particularly hyperkalemia, renal impairment, and blood pressure control, is essential for optimal management.

References

• McMurray, J. J., et al. (2014). ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012. European Heart Journal, 33(14), 1787–1847.
• O’Gara, P. T., et al. (2013). 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction. Journal of the American College of Cardiology, 61(4), e78–e140.
• Pitt, B., et al. (2014). Spironolactone for heart failure with preserved ejection fraction. New England Journal of Medicine, 370(15), 1383–1392.
• Stone, N. J., et al. (2014). 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk. Journal of the American College of Cardiology, 63(25 Part B), 2889–2934.
• Whelton, P. K., et al. (2018). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults. Hypertension, 71(6), e13–e115.
• Yancy, C. W., et al. (2017). 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure. Circulation, 136(6), e137–e161.