Your responses should be in a well-developed paragraph (300-350 words). Integrating an evidence-based resource that is different than the one you used for the initial post.
Respectfully agree and disagree with your peers responses and explain your reasoning by including your rationales in your explanation.
Here is the initial post to a case study (attached is the original case study). Please create a response to the following post:
List specific goals of treatment for Michael.
The goals of therapy in heart failure patients are to reduce mortality and cardiovascular events and to improve health-related quality of life outcomes (Okunade, 2019.) An example of this is decreasing symptom burden or enabling patients to perform their activities of daily living more effectively. We want to decrease the overload of the heart, improve contractility, and decrease his heart rate (Woo, 2020, p. 1104). Doing so can reduce the symptom severity of the disease process.
What drug(s) would you prescribe? Please provide rationales.
I would prescribe Michael 25mg of captopril to be taken by mouth three times a day with one refill. Captopril is an ACE inhibitor. For patients with hypotension or a concern with a diuretic causing sodium depletion the initial dose would be 6.25mg three times a day but Michael does not have those concerns at this time (Drugs.com, 2021). It is recommended to start with a low dose to prevent risks of hypotension and hypoperfusion (Woo, 2020, p. 1109). I would then titrate up until a dose of 50mg in a few weeks if his blood pressure remained stable and no other adverse effects were communicated. After a dose of 50 mg three times a day is reached, further increases in dosage should be delayed, where possible, for at least two weeks to determine if a satisfactory response occurs (Drugs.com, 2021). ACE inhibitors reduce preload and afterload of the heart by acting on the RAAS system and prevent the production of angiotensin II and aldosterone (Woo, 2020, p. 1104). Inhibition of the RAAS and his sympathetic nervous system produces vasodilation and that vasodilation increased cardiac output and decreases myocardial oxygen demand (, 2021). Preload and afterload reduction provide symptomatic relief. Preventing both angiotensin II and aldosterone reduces hypertrophy and fibrosis in the left ventricle (Woo, 2020, p. 1104). ACE inhibitors have been proven to reduce morbidity and mortality in a range of cardiovascular conditions (Leong, 2019).
What are the parameters for monitoring the success of your selected therapy?
Baseline CP and a pulse reading should be taken before initiating therapy with an ACE inhibitor and with each change in dosage (Woo, 2020, p. 283). Weight should also be monitored as well as any edema present. (Woo, 2020, p. 283). Other fluid status components to look at are JVD, the presence of lung crackles, hepatomegaly, and orthostatic BP (Woo, 2020, p.1115). Monitoring serum creatinine levels is important and reducing the dose of captopril will be necessary if creatinine is more than 2.5mg/dL (Woo, 2020, p. 283). This would show the kidneys are not doing well with the medication. Overall, if the patient has increased functional capacity, a regular cardiac rhythm on ECG, and the lab tests are normal, the practitioner can be confident the selected therapy is effective in helping with heart failure (Woo, 2020, p. 1115).
Discuss specific patient education based on the prescribed therapy.
ACE inhibitors such as captopril are appropriate for all patients unless they are pregnancy, have bilateral renal stenosis, have a potassium level above 5.5mEq, or a history of angioedema (Woo, 2020, p. 1109). Blood pressure monitoring is also critical because it ensures renal perfusion but also if the blood pressure is too low it can cause dizziness and falls (Woo, 2020, p. 1109). A dry cough can occur in up to 15 % of patients (Woo, 2020, p. 1109). If this cough is troublesome the patient can be switched to an ARB. Patients should be encouraged to obtain the annual flu shot unless they are allergic (Woo, 2020, p. 1115). Michael should also be educated on self-monitoring of symptoms including daily weights, what to do if symptoms worsen and the need to regularly follow up with their primary care provider (Woo, 2020, p.1115). Exercise training may improve functional capacity, quality of life and reduce hospitalization (Jaarsma, 2020).
Describe one or two drugdrug or drugfood interactions for the selected agent(s).
Michael is currently taking 50mg/d of hydrochlorothiazide. Hydrochlorothiazide is a thiazide diuretic (Woo, 2020, p. 1105). Thiazide diuretics may enhance the hypotensive effect of ACE inhibitors (Lexicomp, 2022). Monitor for symptomatic hypotension and renal failure with this combination of drug therapy (Lexicomp, 2022). The goal with diuretics is to give the lowest possible dose that achieves the desired effect (Woo, 2020, p. 1111). If blood pressure is an issue lower the dose of hydrochlorothiazide.
Michael is also on Indocin which is an NSAID. Since Captopril is an ACE inhibitor it may enhance the toxic effect of any NSAIDs taken (Lexicomp, 2022). The combination of captopril and Indocin may result in reduced renal function (Lexicomp, 2022).
List one or two adverse reactions for the selected agent(s) that would cause you to change therapy.
Angioedema involving the extremities, face, lips, mucous membranes, tongue, glottis or larynx has been seen in patients treated with ACE inhibitors, including captopril (Drugs.com, 2021). Angioedema occurs in about 0.2% of patients that take an ACE inhibitor (Woo, 2020, p. 273). This is related to an increase in the bradykinin level (Woo, 2020, p. 273). If this happens the captopril must be discontinued, and the patient can be switched to an ARB such as 100mg daily of Losartan because ARBs do not affect the bradykinin system (Woo, 2020, p. 273).
What would be the choice for the second-line therapy?
Captopril is indicated in the treatment of congestive heart failure usually in combination with diuretics (Drugs.com, 2021). Diuretics are effective in preload reduction by increasing sodium excretion and decreasing fluid retention, with improvement in cardiac function symptoms and exercise tolerance (Kaiser, 2021). If ACE inhibitors and the hydrochlorothiazide are not effective in helping Michael, I would add a Beta blocker such as 3.125mg of carvedilol twice a day by mouth. Beta blockers are shown to increase life expectancy in patients with heart failure (Woo, 2020, p. 1110).
What over-the-counter or alternative medications would be appropriate for Michael?
Aspirin is an over-the-counter medication that Michael could use. Aspirin interferes with platelet aggregation by antagonizing the cyclooxygenase pathway (Woo, 2020, p. 393). It can be used the help prevent against an MI or stroke (Woo, 2020, p. 393).
An ARB is an acceptable alternative to an ACE inhibitor if the cough is something that Michael cannot tolerate. (Leong, 2019).
What dietary and lifestyle changes should be recommended for Michael?
The above history does not indicate Michaels weight but if he is overweight it is recommended that he lose weight. The general recommendation is to promote healthy lifestyle and weight loss, preferring plant-based food over animal-based, processed foods and added sugar (Jaarsma, 2020). Avoid excess of salt intake and large amounts of fluid intake (Jaarsma, 2020). Nonadherence with the recommended treatment regimen may decrease life expectancy and will affect their overall quality of life so it is important Michael follow his new medications (Woo, 2020, p.1116). Limit alcohol intake to two drinks a day (Jaarsma, 2020).
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