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