Heart Failure and Lipid Disorder Therapy

Introduction

As future nurse practitioners, you will treat patients with various conditions and will need to critically think through various pathways to establish differential diagnoses that ultimately lead to your final treatment plan.

In this case scenario, you will meet 65-year-old white woman, Megan Hamilton. Use the information about the patient, along with knowledge from course materials and clinical experience, to complete the case analysis.

About the Patient

A 65-year-old white woman, Megan Hamilton, presents to the emergency department with orthopnea and paroxysmal nocturnal dyspnea in recent days; worsening dyspnea on exertion for the past few months and now dyspnea at rest; and pedal edema. She has a history of dyslipidemia, type 2 diabetes mellitus, hypertension, and coronary artery disease (status post 3-vessel bypass surgery two years ago). She denies any chest pain on exertion or at rest. She reports a history of osteoarthritis.

Patient Facts

Allergies/Intolerances

Intolerant to ACE inhibitors due to a cough
No known drug allergies

Current medications

Amlodipine (Norvasc) 2.5 mg each morning
Losartan (Cozaar) 100 mg each morning
Enteric-coated aspirin 81 mg daily
Rosuvastatin (Crestor) 20 mg each day
Metformin (Glucophage) 1 gram twice a day
Ibuprofen 600 mg three times a day

Social history

Nonsmoker
Does not drink alcohol

Vital signs

Heart rate: 105 beats per minute
Respiratory rate: 22 breaths per minute
Blood pressure: 130/80
Room air oxygen saturation on pulse oximetry: 90%

Physical exam

BMI: 25
Lungs: Diffuse crackles
Heart: +S1, +S2 with regular rate and rhythm. No audible murmur. No extra heart sounds auscultated.
Neck: Elevated jugular venous pressure
Extremities: 2+ pitting edema

Testing

Echocardiogram: Ejection fraction of 34%
Chest x-ray: Diffuse vascular congestion. No pleural effusion.
Electrocardiogram: Sinus tachycardia without evidence of acute ischemia; positive for left ventricular hypertrophy changes
B-type natriuretic peptide level: Significantly elevated
High sensitivity troponin: Normal
TSH: Normal
Comprehensive metabolic profile: Normal values except for a non-fasting blood sugar of 250 mg/dl
CBC: Normal
Lipids: HDL cholesterol (HDL-C) 30 mg/dl; LDL cholesterol (LDL-C) 120 mg/dl; triglycerides (non-fasting) 400 mg/dl
Hemoglobin A1C: 9.1 percent

Questions

What initial therapy, care plan, and medications would you prescribe for Megan, considering her current medications, acute presentation, and diagnoses?

Include your rationales for each of the acutely prescribed medications.

Once she is hemodynamically stable, what additional class(es) of medications should be added to her heart failure medication regimen and why?

What long-term therapy should be initiated for her lipid disorder? What is your rationale for choosing this therapy? What are the precautions, contraindications, and potentially serious adverse effects that might occur due to this class of medications?

What follow-up and monitoring are indicated, both acutely and long term, to manage her lipid disorder, diabetes mellitus, and heart failure with reduced ejection fraction, including the medications prescribed for these? What should Megan’s hemoglobin A1C goal be?

What non pharmacologic therapies might benefit Megan?

List at least three current scholarly references you used, in APA style. (The text box will not allow for hanging indentation or italics. Otherwise, follow APA format.)

Summary

Enter your first and last name, then select the submit button to get your summary.

If you would like to try again, select the Restart Activity button or follow the instructions to print your answers.

Select the Print button to print or save a copy of this document. Your browser’s print window will then appear. To save as a PDF document, select Adobe PDF in the Select Printer (Firefox) or Destination (Chrome) options. Then, select Print to save this document as an Adobe PDF document to your computer.