This study represents a case scenario of a patient named Deependra Sidhu (Deep) who is a 68-year-old male and having a past medical history of angina, hypertension, myocardial infarction, angina, and High cholesterol with type 2 diabetes. He was on a combination of certain medications for all the related illnesses such as β- blockers, diuretics, nitrates, and statins, etc. one day after lunch he was admitted to the hospital because he was complaining of breathlessness and pain in the chest. The nurse has advised him to go for some blood tests and ECG so that she can find the main cause behind the condition of the patient. There he was observed continuously by the nurse, and observations were made at regular intervals to regular follow-up the patient. His counseling about medications and their adverse effects was also discussed with the patient to guide them.
The buddy nurse requests the ECG report of the Deependra Sidhu, as it is a medical test that detects heart problems by measuring the heart-generated electric activity as it contracts. [Coviello, J. S. 2017]. Deependra Sidhu is overweight, high cholesterol, diabetes, or high blood pressure. He also displays symptoms such as breathlessness, chest pain. The electrocardiogram procedure is safe and non-invasive with no account is known risks.
The buddy nurse requests the blood report of the Deependra Sidhu, as Cardiac biomarkers show up in the blood after the heart has been under severe stress and due to getting insufficient oxygen, it becomes injured also includes hormones, proteins, and enzymes. Troponin T enters into the bloodstream shortly after a heart attack. It stays in the bloodstream every day even after all other biomarkers return to normal levels. [Ettinger, S. 2016]. It includes the CK-MB that is a subtype of CK. As CK-MB is more sensitive for discovery damage of heart from a heart attack. It rises four to six hours after a heart attack. But generally, it is back to normal in 1 or 2 days.
Heart failure in the patient is when the heart is unable to pump the right amount of blood to meet the demands of the body. It may occur because there is some abnormality in the muscles of the heart due to some problems in valves and rhythm of the heart as shown by ECG of the Deep. It may lead to both rights and left heart failure. It may occur due to reduction of cardiac output that may result in activation of two compensatory mechanisms:
Compensatory mechanism of the sympathetic nervous system: In this mechanism, Beta-1 cells in the heart are stimulated which leads to a decrease in the release of catecholamines due to which baroreceptors result in the decrease of blood pressure. It will increase heart rate, stroke volume, and ultimately cardiac output as observed in our patient. In long term, this mechanism in the patient may increase heart failure.
Compensatory mechanism of Renin-angiotensin-aldosterone (RAA): As this pathway controls the blood pressure and electrolytes in the body. [Jefferies, J. 2017] This mechanism is altered in deep (patient) which results in retention of fluids, salts, and constriction of blood vessels. If it is activated for a long -term it may lead to an increase in dysfunctioning of the heart and remodeling of the heart.
It will result in the activation of the following response mechanism of the heart:
Ventricular function is impaired, and a high amount of preload is necessary to maintain cardiac output. In this condition, the stress in the walls of the heart increases and results in the increase of demand for oxygen and the death of cells of the myocardium. It increases the dilation of the ventricles of the patient that increases the end-diastolic volumes of the heart.
Responses related to Kidney:
The flow of blood to the kidney decreases because there is a decrease in cardiac output. Pressure in renal veins increases which results in congestion of renal veins. This results in a decrease in glomerular filtration rate and the flow of blood within the kidneys are distributed again.[ Lilly, L. S. 2016] Decrease in the amount of filtered sodium and reabsorption of filtration fraction in tubules increases, which leads to retention of sodium and water in the blood. As the patient is having observations like Oedematous legs, moderate pitting edema due to this retention of various ions. All these effects are increased due to the activation of the sympathetic nervous system and results in worsening of heart failure in the patient.
Responses related to Neurohumoral:
As the patient is undergoing stress responses related to neurohumoral results in the increase of function of the heart and maintaining blood pressure. But there is chronic activation of these responses which results in deterioration of balance between various myocardial stimulating and vasoconstricting hormones.
Various factors like Atrial natriuretic peptide are released due to an increase in volume and pressure of arteries, Brain natriuretic peptide is also increased from ventricles due to the stretching of ventricles. In our patient heart failure may be due to decreases in pressure of renal perfusion and downregulation of receptors with the increase in degradation of enzymes.[ Martindale, J. 2016] An increase in the level of these peptides results in a counter-regulation effect on the renin-angiotensin-aldosterone system and stimulation and release of catecholamines in their sympathetic nervous system.
Changes with the increase in age of the patient:
Changes related to age in the heart increase heart failure. Collagen in the interstitial muscles of the heart increases due to which stiffness increases in the myocardium and relaxation of myocardial muscles occur. Due to these changes, systolic function declines with an increase in age in deep. Therefore, impairment of cardiovascular activity occurs due to an increase in demand for work.
As there is the poor progression of R- Wave, it may also be a sign of myocardial infarction previously. Therefore, it can be interpreted from the ECG [TAHLAWI M. 2020] that the patient is having severe disorders of heart or heart failure due to various types of abnormalities found in his ECG.
The physiology of occurring of short of breath Deep has during his overnight admission is caused by the reduced ability of the heart to empty and fill that producing raised pressures in the blood vessels nearby the lung. Usually, the cause of heart failure is heart muscle damage. It is happening in the majority of patients with a heart attack. In few patients caused through narrowing or leakage of the heart valves, by toxins weakening of the heart muscle happen, hereditary factors, viral infections.
A single risk factor may be sufficient to cause heart failure, but the risk increase by the combination of factors. The two of the factors that exacerbate deep heart failure are:
As Deep as taking a combination of various medication for hypertension may result in the increase of hypotension due to administration of sildenafil with them.[ Martindale, J. 2016] He should be informed of not taking nitrates within 24 hours of taking Viagra because it may lead to severe hypotensive effects.
As nitrates release Nitric oxide and they are used in the treatment of angina. Administration of nitric oxide donors with sildenafil can result in a great reduction of blood pressure in patients of angina with a high risk of erectile dysfunction in them when both medications are co-administered within 24 hours of each other. If the dose of glyceryl trinitrate (0.4 mg spray) after sildenafil (100 mg) is prescribed, their interaction lasts for less than 4 hours in healthy individuals leads to interaction between them.
He should not be prescribed short-acting nitrates for 24 hours and long-acting nitrates for 72 hours after prescribing sildenafil.
All these factors should be kept confidential and personal to gain the confidence of the patient.
All his Medical information and records should also be kept confidential and there should not be any breach of data.
Beta-Blockers, Beta-1 Selective
High Ceiling Diuretics
Mechanism of action
It acts by binding to β-1 adrenergic receptors that are present in vascular smooth muscles and the heart. They act by blocking the inotropic and chronotropic actions of various catecholamines [ Lilly, L. S. 2016] such as adrenaline, nor-adrenaline, and isoproterenol.
It promotes diuresis by inhibiting Na+-K+ 2 Cl- co-transporter in the thick ascending limb of the loop of Henle. It inhibits the tubular reabsorption of sodium and chloride in the proximal and distal tubules. [Yakar, T., 2016] With this, there is an increase in the excretion of water, sodium chloride, magnesium, calcium, and hydrogen.
Take the medicine with the meal if GI upset occurs.
Do not engage in any driving activity or any dangerous activity if weakness or dizziness occurs.
Do not take stop the intake of medicine until mentioned by a health professional.
Some side effects like nightmares, dizziness, light-headedness, depression, etc. may be experienced by the patient.
Advice the patient to take this medicine with milk or food to prevent upset of the gastrointestinal tract.
Consult with the health care professional if the patient is having dry mouth, thirst, lethargy, weakness, or hypotension.
With other anti-hypertensives additional therapies needed are less sodium intake, weight loss, reducing stress, regular exercise, less consumption of alcohol, No smoking are3 advised to the patient.
As deep is complaining of severe gastrointestinal upset, therefore, he stopped taking his medication. [ Yakar, T., 2016]
Second, he was continuously having a dry mouth, weakness, and drowsiness. [Zahálka L, 2018]
He was consuming some amount of alcohol which leads to the reaction of the furosemide. [Leclerc, S., et al 2019].
Therefore, the nurse has advised deep to take all his medicines with milk or food. He should also continuously do some exercises, eat low sodium food, take less stress and reduce the consumption of alcohol.
As we have seen in our study, that the patient is experiencing severe heart failure. Therefore, he should be continuously monitored and observed by the nurse to take good care of him. The patient should be treated according to the guidelines and should be advised to follow the dosage regimen as prescribed. It will build a relationship of trust between the health care professional and the patient. Also, it will help the patient to recover faster. It should be concluded from our study that the patient who is treated well by the health professionals will always recover faster.
Coviello, J. S. (Ed.). (2017). Ecg interpretation made incredibly easy! : pocket guide (Third, Ser. Incredibly easy pocket guide). Wolters Kluwer.
Ettinger, S. (2016). Nutritional pathophysiology of obesity and its comorbidities: a case-study approach. Academic Press.
Jefferies, J. L., Chang, A. C., Rossano, J. W., Shaddy, R. E., & Towbin, J. A. (2017). Heart failure in the child and young adult : from bench to bedside. Elsevier Science.
Lilly, L. S. (Ed.). (2016). Pathophysiology of heart disease : a collaborative project of medical students and faculty (Sixth, Ser. Books@ovid). Wolters Kluwer.
Leclerc, S., Laurin, L. P., Lafrance, J. P., Lamarche, C., Ouimet, D., Paquette, F., … Nadeau-Fredette, A. C. (2019). Pharmacodynamics of 250 mg and 500 mg oral furosemide in peritoneal dialysis . International Journal of Clinical Pharmacology and Therapeutics, 57(12), 603–606. https://doi.org/10.5414/CP203594
Martindale, J. L., & Brown, D. F. (2016). A visual guide to ecg interpretation (2nd ed.). Wolters Kluwer Health. https://public.ebookcentral.proquest.com/choice/publicfullrecord.aspx?p=5122316.
TAHLAWI, M. O. H. A. M. M. A. D. E. L. (2020). Heart failure in pediatric patients (Ser. Frontiers in heart failure series). BENTHAM Science PUBLISHER
Yakar, T., Demir, M., Dogan, O., Parlakgumus, A., Ozer, B., & Serin, E. (2016). High dose oral furosemide with salt ingestion in the treatment of refractory ascites of liver cirrhosis. Clinical and Investigative Medicine. Medecine Clinique Et Experimentale, 39(6), 27502–27502.
Zahálka L, Klovrzová S, Matysová L, Šklubalová Z, & Solich, P. (2018). Furosemide ethanol-free oral solutions for paediatric use: formulation, hplc method and stability study. European Journal of Hospital Pharmacy : Science and Practice, 25(3), 144–149. https://doi.org/10.1136/ejhpharm-2017-001264
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