Psychotherapy replies

POST # 2 LINDSEY

The purpose of this discussion is to evaluate ML for her recent diagnosis of Stage A heart failure and discuss what pharmacological agents suit her best. Roughly about 6.2 million Americans suffer from heart failure and it is very costly for our healthcare system (Virani, Alonso, Benjamin, Bittencourt, Callaway, Carson, & Tsao, 2020).  Heart failure is a progressive, chronic disease in which the heart muscle is unable to pump enough blood, seen with the ejection fraction, to meet the body's required needs to provide adequate amount of blood and oxygen to vital organs and tissues (AHA, 2020). This disease can involve the heart’s left side, right side or both sides, usually affecting the left side first (AHA, 2020). The heart is unable to keep up with the desired workload and tries to compensate by working and contracting stronger which eventually leads to enlargement, more muscle mass, and pumping faster (AHA, 2020). Unfortunately, this disease is not curable and these temporary compensatory measures only last for so long, resulting in the heart to not be able to keep up. As a result, the patient will experience symptoms such as fatigue and respiratory problems which usually warrant medical treatment (AHA, 2020). 

There are four stages to heart failure including, A, B, C and D. Per the American Heart Association (AHA, 2020) Stage A heart failure, also considered "pre-heart failure" are patients who are considered high risk for heart failure but they are without structural heart disease or symptoms of heart failure. Patients who would be considered high risk for heart failure include, hypertension, atherosclerosis, diabetes, obesity, metabolic syndrome, patients using cardiotoxins, and someone with a family history of cardiomyopathy (AHA, 2020). Given that ML is a retired registered nurse with an extensive medical background, she is not wrong that digoxin is one of the drugs of choice that treats heart failure. For her case, she would not be prescribed digoxin due to the stage of heart failure she is in based of the AHA (2020) recommended guidelines for management of heart failure. As an APRN, the patient would be educated on this current data, but I would also address her concerns about the side effects of digoxin, if she was to ever need this medication down the road. Halos, also known as xanthopsia, is a classic side effect of digoxin when the patient has toxic levels in the blood causing an appearance of yellow halos around the light (Haruna, Kawasaki, Kikkawa, Mizuno, & Matoba, 2020). To avoid digoxin toxicity, it is important for patient to get their levels drawn accordingly (Haruna, Kawasaki, Kikkawa, Mizuno, & Matoba, 2020). To avoid digoxin toxicity, it is important for patient to get their levels drawn accordingly.  Based off these current guidelines ML in the pre-heart failure stage, would be prescribed an ACE inhibitor, and or angiotensin-receptor blocker if she has vascular disease or diabetes, as well as a statin if necessary (AHA, 2020). Based off these current guidelines ML in the pre-heart failure stage, would be prescribed an ACE inhibitor, and or angiotensin-receptor blocker if she was to have vascular disease or diabetes, as well as a statin if necessary (AHA, 2020). 

When prescribing patients medications as an APRN it is important to note the gender-related differences in the anatomy and physiology of the cardiovascular system, for example body composition, role of hormonal changes during menstruation, pregnancy, and menopause (Tamargo, Rosano, Walther, Duarte, Niessner, Kaski, & Agewall, 2017). A recent study also notes that there are also gender-related differences in the pharmacokinetics and pharmacodynamics of cardiovascular drugs. Given that ML would most likely be started on an ACE inhibitor, this study notes that there is no mortality benefit in women with asymptomatic left ventricular systolic dysfunction and women are 2 to 3 times more likely to experience the common side effect of a dry cough than men (Tamargo et al., 2017). Before starting an ACE inhibitor, it is important to check blood levels, specifically urea, creatinine, potassium, and sodium values (Edren, 2018). Evidence shows major risk factors from ACE inhibitors are hyperkalemia and deterioration of impaired renal function (Edren, 2018). Given the blood levels are adequate, the drug can be started with a recommendation to check blood levels and blood pressure within one week (Edren, 2018). If titration of the drug is warranted, it is recommended to continue monitoring blood levels and blood pressure until at desired dose (Edren, 2018). Given that digoxin was a concern to ML and a popular drug therapy for heart failure, it is notable that women have an increased risk of mortality on digoxin and require lower doses and plasma serum levels, recommended level being <0.08ng/ml. Given the blood levels are adequate, the drug can be started with a recommendation to check blood levels and blood pressure within one week. If titration of the drug is warranted, it is recommended to continue monitoring blood levels and blood pressure until at desired dose. Given that digoxin was a concern to ML and a popular drug therapy for heart failure, it is notable that women have an increased risk of mortality on digoxin and require lower doses and plasma serum levels, recommended level being <0.08ng/ml (Tamargo et al., 2017).  Women appear to have higher serum digoxin levels due to reduced volume of distribution and lower clearance than men (Tamargo et al., 2017).  

References

American Heart Association (AHA). (2020). Stages of Heart Failure and Recommended Therapy by Stage 1 / 1. Retrieved from  https://www.heart.org/-/media/data-import/downloadables/8/c/2/rahf-guidelines-toolkit-algorithm-pdf-ucm_492569.pdf?la=en

American Heart Association (AHA). (2020). What is Heart Failure? Retrieved from  https://www.heart.org/en/health-topics/heart-failure/what-is-heart-failure

Edren. (2018). ACE Inhibitors: How to start. Retrieved from  http://edren.org/ren/gp-info/ace-inhibitors-how-to-start/

Haruna, Y., Kawasaki, T., Kikkawa, Y., Mizuno, R., & Matoba, S. (2020). Xanthopsia Due to Digoxin Toxicity as a Cause of Traffic Accidents: A Case Report. The American Journal of Case Reports, 21.

Tamargo, J., Rosano, G., Walther, T., Duarte, J., Niessner, A., Kaski, J., . . . Agewall, S. (2017). Gender differences in the effects of cardiovascular drugs. European Heart Journal - Cardiovascular Pharmacotherapy, 3(3), 163-182.

Virani, S. S., Alonso, A., Benjamin, E. J., Bittencourt, M. S., Callaway, C. W., Carson, A. P., . . . Tsao, C. W. (2020). Heart Disease and Stroke Statistics—2020 Update: A Report From the American Heart Association. Circulation, 141(9).