Congestive Heart Failure Case Presentation
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The document presents a case study of a 45-year-old female patient with congestive heart failure (CHF), emphasizing the diagnosis, causes, incidence, and treatment of CHF. Various treatment plans and medications were administered throughout her hospital stay, leading to significant improvement in her condition and stabilization before discharge. Key considerations regarding the management of patients with overlapping conditions like chronic kidney disease and heart failure are also discussed.
Congestive Heart Failure Case Presentation
- 1. C O N G E S T I V E H E A RT FA I L U R E : C A S E P R E S E N TAT I O N C C U , H E A RT WA R D 1 . Presented by : Walaa Fahad Al-Juaid , Manal Awn Al- Osaimi
- 2. O U T L I N E S : •T H E C A S E . •W H AT I S T H E C H F •D E F I N I T I O N •C A U S E S •I N C I D E N C E A N D P R E VA L E N C E •D I A G N O S I S •C O M P L I C AT I O N •T R E AT M E N T •I N T E R V E N T I O N
- 3. T H E C A S E : • S. a 45 years old female come to the hospital complaining of shortness of breath , left side weakness , bilateral foot swelling and did not take any hypertensive medication .
- 4. H I S T O RY O F P R E S E N T I L L N E S S ▸Patient is bed ridden with chronic kidney disease, Ischemic heart disease and hypertension . ▸Family history : Unknown ▸Allergy : No Kind of Allergy . ▸Medication history : Coversyl .
- 5. R E V I E W O F S Y S T E M S : ‣ Eyes: normal ‣ Mental status: conscious . ‣ Respiratory system: Normal sounds ‣ Cardiovascular system: S1+S2+S4 ‣ Chest wall & breast: No any diseases ‣ Abdomen: soft and lax . ‣ Extremities : Bilateral Edema
- 6. V I TA L S I G N O N A D M I S S I O N ▸ Normal Ranges : ▸ Patient Vital sign : Temperature PR RR O saturation BP 36-37 60-100 16-20 > 96% 120/80 Temperature PR RR O saturation BP 37 100 20 96% 174/121
- 7. C B C A N D L A B R E S U LT S : Normal Ranges WBC 10^9/uL RBC 10^12/uL Hb g/dL 4-10 x10^9/L 4,5 -5,5 X10^12/L 12-16 WBC 10^9/uL RBC 10^12/uL Hb g/dL 4 4.5 10 Patient’s Ranges
- 8. Albumin K Na sCr 3.5-5.2 3.5-5.3 135-153 0.7-1.2 Normal Ranges Albumin K Na sCr 2.5 3.3 136 1.6 Patient’s Ranges
- 9. F I N A L D I A G N O S I S : C O N G E S T I V E H E A RT FA I L U R E
- 10. W H AT I S C O N G E S T I V E H E A RT FA I L U R E ? • Congestive heart failure (CHF) is a chronic progressive condition that affects the pumping power of the heart muscles. • While often referred to simply as “heart failure,” CHF specifically refers to the stage in which fluid builds up around the heart and causes it to pump inefficiently.
- 11. W H AT A R E T H E M O S T C O M M O N T Y P E S O F C H F ? Left-sided CHF is the most common type of CHF. It occurs when the left ventricle doesn’t properly pump blood out to the body. As the condition progresses, fluid can build up in your lungs, which makes breathing difficult. Right-sided CHF occurs when the right ventricle has difficulty pumping blood to the lungs. Blood backs up in the blood vessels, which causes fluid retention in the lower extremities, abdomen, and other vital organs.
- 12. W H AT A R E T H E M O S T C O M M O N T Y P E S O F C H F ? O U R PAT I E N T
- 13. W H AT A R E T H E C A U S E S O F C H F ? • Hypertension • Coronary artery disease • Valve conditions : Valves that don’t open and close correctly may force ventricles to work harder to pump blood and this can be a result of a heart infection or defect. • Diabetes, thyroid disease and obesity O U R PAT I E N T
- 14. I N C I D E N C E A N D P R E VA L E N C E • In several Middle Eastern countries, like Oman, Saudi Arabia, and Yemen, around 52% of HF cases are secondary to IHD ,valvular heart disease also remains a prevalent cause of HF in the Middle East, where it accounts for 22.5% of HF cases in Egypt , 10.5% of cases in Saudi Arabia , 8.4% in Oman, and 7% in Yemen.
- 15. • The prevalence of risk factors for HF is increasing. For example, 26% of the Saudi population is affected by hypertension and approximately 24% is affected by diabetes mellitus. • Patients with diabetes are at a higher risk for developing HF
- 16. D I A G N O S I S • Physical exam may involve listening to your heart with a stethoscope to detect abnormal heart rhythms • Electrocardiogram (ECG) records heart’s rhythm. • An echocardiogram uses sound waves to record the heart’s structure and motion. The test can determine poor blood flow, muscle damage, or a heart muscle that doesn’t contract normally.
- 17. • MRI takes pictures of heart. With both still and moving pictures, this allows doctor to see if there’s damage . • Stress tests show how well the heart performs under different levels of stress. • Blood tests • Cardiac catheterization can show blockages of the coronary arteries.
- 18. T R E AT M E N T • Heart failure is a serious illness that can affect life. However, generally, treatment depends on the NYHA classification or (Stages) and underlying medical condition. • The major types of heart failure treatment includes: • Lifestyle changes • Heart Medications • Surgery for correctable problems • Implantable devices • Heart transplant .
- 19. O U R PAT I E N T
- 20. C O M P L I C AT I O N S : • Atrial fibrillation • Ventricular fibrillation or tachycardia . • Kidney failure • Anemia • Cardiac cachexia • Heart valve condition • Stroke O U R PAT I E N T
- 21. B A C K T O T H E C A S E :
- 22. F I R S T D AY : • Patient came to the ER complaining of complaining of shortness of breath , left side weakness , bilateral foot swelling . Drug name Dose frequency Route of administration Nifedipine 20 mg - oral Furosemide 40 mg - IV
- 23. A S S E S S M E N T • The patient is a hypertension patient’s and she did not adhere to hypertension management plan • She also has A CKF stage 3 B ( GFR = 30-40) , LVEF = 20% , So she transferred to the CCU to manage her CHF. • They give her Frusemide as a diuretic for edema , and Nifedipine to reduce her BP .
- 24. S E C O N D D AY • In the CCU she treated on plan ( NYHA Class III/IV ) according her symptoms and LVEF reading . Drug name Dose frequency Route of administration Nifedipine 60 mg OD Oral Furosemide 40 mg TID IV Aspirin 81 mg OD Oral Metolazone 2.5 mg OD Oral Atrovastatin 40 mg OD Oral Telmisartan 40 mg OD Oral Carvedilol 6.25 mg BID Oral Enoxaparin 3000 IU OD S.C Nitroglycerin 5 mcg/min OD IV
- 25. ▸ Patient Vital sign : ▸ CBC : ▸ LAB Temperature PR RR O saturation BP 36.5 70 20 95% 136/70 I M P R O V E D WBC 10^9/uL RBC 10^12/uL Hb g/dL 4 4.5 10 Albumin K Na Mg 1.7 3.4 136 1.4 N O R M A L ( 1 . 6 - 2 . 6 ) M G / D L
- 26. A S S E S S M E N T • They use NYHA III plan management as they mention on patient profile • The patient take Nifedipine, Telmisartan, Carvedilol to control her hypertension and she is improving on it . • Furosemide and Metolazone to reduce bilateral edema • Aspirin and Enoxaparin to prevent Ischemia , Stroke or any coagulation events • Nitroglycerin to get benefit to CHF and Renal failure • Also they add Isosorbide 10 mg Tablet TID as recommendation in the guideline .
- 27. • Atrovastatin for control her lipid profile her total Cholesterol was 208 which was slightly abnormal and her LDL was 129.4 ( normal = 00-100 ) . • They did not use digoxin because the patient symptoms improve and did not use spironolactone due to CKD . • ECG confirm the diagnosis of CHF .
- 28. T H I R D D AY : • Patient improve on the medication , so they keep the same plan they just add Mg sulphate 4 g IV and Human Albumin 20% 50 ml BID IV . • Vital sign : Temperature PR RR O saturation BP 36.5 68 20 97% 140/90
- 29. ▸ CBC : ▸ LAB WBC 10^9/uL RBC 10^12/uL Hb g/dL 4 4.5 10 Albumin K Na Mg 1.7 3.5 138 1.4 N O R M A L ( 1 . 6 - 2 . 6 ) M G / D L
- 30. A S S E S S M E N T • The patient continue the same plan , her blood pressure effected by diuretics and antihypertensive agent • They discontinue furosemide to avoid hypokalemia but keeping use Metolazone to control fluid retention . • Using Mg sulphate to control Mg levels . • Using Human Albumin to Control Albumin levels .
- 31. F O U RT H D AY • They keep the same plan, patient is stable so they transfer her to female medical word for only observation . • Vital sign : Temperature PR RR O saturation BP 36.5 68 20 97% 138/82
- 32. ▸ CBC : ▸ LAB WBC 10^9/uL RBC 10^12/uL Hb g/dL 4 4.5 10 Albumin K Na Mg 2.9 3.5 138 1.6 N O R M A L ( 1 . 6 - 2 . 6 ) M G / D L I M P R O V E D I M P R O V E D
- 33. A S S E S S M E N T • The patient’s blood pressure is stable on the medication , they continuo the same plan . • Mg level is improve so they discontinue Mg sulphate . • Still using Human Albumin to Control Albumin levels .
- 34. F I F T H D AY • Patient discharge after her Albumin reach 3.5 which is improved to the normal levels and her blood pressure reaching the target and stable on the antihypertensive medication . • Vital sign : Temperature PR RR O saturation BP 36.5 68 20 97% 123/74 TA R G E T > 1 2 5 / 7 5 .
- 35. A S S E S S M E N T : • Keep using antihypertensive ( BB , Diuretic ,ARB , Nitrate ) medication to control blood pressure and Atrovastatin to control lipid Aspirin + Clopidogrel 75Mg tablet to prevent ischemia because the patient has history ischemic heart disease . • Educate the patient about the important of her medication to help her to adherence . • Home visit doctors to continue observation to the patient .
- 36. I N T E R V E N T I O N :
- 37. G O A L S O F T R E AT M E N T : • (1) to decrease the preload and afterload and to reduce LVH • (2) to treat myocardial ischemia. • (3) to inhibit neurohumoral hyperactivity, especially the sympathetic nervous system and the renin- angiotensin-aldosterone system .
- 38. T R E AT M E N T A C C O R D I N G N Y H A C L A S S I F I C AT I O N : Patient Bedridden high Blood Pressure Shortness of breath PAT I E N T M E D I C AT I O N : 1 - T E L M I S A RTA N 2 - C A R V I D I L O L 3 - F U R O S I M I D E 4 - M E T O L A Z O N E 5 - I S O S O R B I D E D E N I T R AT E
- 39. A C C O R D I N G T O T H E G U I D E L I N E T H E Y H AV E B E E N U S E D : • They give her the medication according guideline + nifedipine because the patient has Hypertension • And also they give her Aspirin and Colpidogrel to prevent recurrence IHD . • Nitroglycerin for CKF and CHF • Atrovastatin to Control lipids . T H I S I S W I L L L E A D U S T O A C C F / A H A G U I D E L I N E F O R T H E M A N A G E M E N T O F H E A RT FA I L U R E
- 40. A C C F / A H A G U I D E L I N E F O R T H E M A N A G E M E N T O F H E A R T FA I L U R E ( 2 0 1 3 ) U P D AT E D ( 2 0 1 7 ) : Stage Definition Of Stage Usual Treatments Stage A People At High Risk Of Developing Heart Failure (Pre-Heart Failure), Including People With: High Bp , D M , C A D . • Exercise Regularly, Quit Smoking. • Treat High Blood Pressure. • Treat High Cholesterol. • (Ace Inhibitor) Or (Arb) For Previous Heart Attack Or Diabetes, High Blood Pressure, Or Other Vascular Or Cardiac Conditions. • Beta Blockers May Be Prescribed For Previous Heart Attack Or High Blood Pressure. Stage B People Who Have Developed Heart Failure But Without Signs And Symptoms Of Heart Failure. • Treatment Methods Above For Stage A Apply. • All Patients Should Take An Angiotensin Converting Enzyme Inhibitor (Ace Inhibitor) Or Angiotensin Ii Receptor Blocker (Arb). • Beta-Blockers Should Be Added For Everyone.
- 41. Stage Definition Of Stage Usual Treatments Stage C Patients With Known Systolic Heart Failure And Symptoms. Most Common Symptoms Include: Shortness Of Breath Fatigue Reduced Ability To Exercise • Treatment Methods Above For Stage A Apply. • All Patients Should Take Ace Inhibitor And Beta-Blocker. • Diuretics And Digoxin May Be Prescribed If Symptoms Persist. • An Aldosterone Inhibitor May Be Prescribed When Symptoms Remain Severe With Other Therapies. • Restrict Dietary Sodium (Salt). • Monitor Weight. • Restrict Fluids (As Appropriate). • Drugs That Worsen The Condition Stage D Patients With Systolic Heart Failure And Presence Of Advanced Symptoms After Receiving Optimum Medical Care. • Treatment Methods For Stages A, B & C Apply. • Patient Should Be Evaluated To Determine If The Following Treatments Are Available Options: Heart Transplant, Ventricular Assist Devices Or Surgery Options O U R PAT I E N T
- 42. S O . . • The plan is good and on the guideline BUT patient is CKF and according to her condition these modification should be conceder : • Loop diuretics should be used as first-line agents in patients with GFR <30 mL/min/1.73 m2 < they do it by using Frousimide. • (2) In patients with CKD and ESRD, anemia has been associated with LV hypertrophy and dilatation, we suggest that in people with CKD and HF anemia should be treated according to the guidelines used in the general CKD population, targeting a serum hemoglobin of 11 to 12 g/dL < they did not treat the anemia
- 43. • According to KDIGO Clinical Practice Guideline for Anemia in Chronic Kidney Disease ( 2012 ) : the Anemia treated by : Using a trial of IV iron (or in CKD patients alternatively a 1–3 month trial of oral iron therapy) if:increase in Hb concentration without starting ESA treatment is desired* and TSAT is r30% and ferritin is r500 ng/ml (r500 mg/l) .
- 44. R E F E R E N C E S : • Mostafa Q Al-Shamiri, Heart Failure in the Middle East,2013 May; 9(2): 174– 178. • Journal of the American College of Cardiology, ACCF/AHA Guideline for the Management of Heart Failure , updated 2017 on website http:// www.onlinejacc.org . • Michelle M. Kittleson, MD, PhD; Jon A. Kobashigawa, MD ,Management of Advanced Heart Failure , April 2011;123:1569-1574. • Liviu Segall, Ionut Nistor, and Adrian Covic , Heart Failure in Patients with Chronic Kidney Disease, 2014 (2014), Article ID 937398, 21. • KDIGO Clinical Practice Guideline for Anemia in Chronic Kidney Disease ( 2012 )