Given the findings of Mr. Russell’s physical exam (weight gain, crackles, and edema) it appears he is retaining fluid, likely related to heart failur
Given the findings of Mr. Russell’s physical exam (weight gain, crackles, and edema) it appears he is retaining fluid, likely related to heart failure (HF), and his lipid profile indicates hyperlipidemia. The treatment goal for Mr. Russell would be to reduce fluid retention and correct his fluid imbalance. Additionally, Mr. Russell’s hyperlipidemia should be treated with medications and diet.
To address Mr. Russell’s current health concern, the HCTZ will be discontinued as the use of thiazides are not recommended in patients with hyperlipidemia (Woo & Robinson, 2016). A loop diuretic, such as furosemide, will be prescribed at a dose of 20mg daily. Studies have shown that prolonged use of high doses of loop diuretics have contributed to poorer outcomes in patients with HF (Damman, et al., 2016), therefore, it is best to start him at the lowest dose possible and monitor for improvement. In addition to the furosemide, Mr. Russell will be prescribed a angiotensin-converting enzyme inhibiter (ACEI). Angiotensin converts to angiotensin II in the renin-angiotensin-aldosterone system (RAAS) when activated by a decrease in cardiac output, causing an increase in blood pressure. In addition, angiotensin II stimulates aldosterone which is responsible for the retention of sodium and water in the kidneys (Woo & Robinson, 2016). Preventing the conversion, allows the activation of bradykinin which is a vasodilator and lowers blood pressure. Due to evidence from random controlled trials, the American College of Cardiology (ACC) and American Heart Association (AHA) recommends ACEI for the treatment of mild to severe HF (Yancy, et al., 2017), and since there are no apparent contraindications such as renal impairment or known drug allergy, is the best option for Mr. Russell. Lisinopril 5mg by mouth daily will be prescribed (Epocrates, 2019).
In regards to Mr. Russell’s elevated cholesterol levels, an additional medication will be prescribed to help lower his lipid levels. According to the guidelines set by ACC (Grundy, et al., 2019), Mr. Russell is considered high-risk due to his age being > 65 years, high blood pressure, and heart failure status. Therefore, it recommended to treat him with a high-intensity or maximal statins (HMG-Coa reductase inhibitors). Mr. Russell will be prescribed atorvastatin 40mg by mouth daily to start, but may be increased to 80mg daily if initial dose is tolerated and target lipid levels are not reached (Epocrates, 2019; Grundy, et al., 2019). Atorvastatin was chosen due to it being save to prescribe with the lisinopril and furosemide, as well as low potential for adverse reactions.
Five key educational points to be discussed with Mr. Russell in regards to his physical finding and new medications include:
Take the medication as prescribed. Lisinopril should be taken at the same time everyday, and if a dose is missed, it should be taken as soon as he remembers unless it is close to the next dose. Furosemide should be taken in the morning to reduce nocturia. Atorvastatin can be taken in the morning or night. The patient should not double up on any missed doses on any of these medications.
The patient should contact the NP if he is thinking of taking any OTC medications, especially cold remedies, and he should avoid taking NSAIDS while on the lisinopril.
Education regarding the adverse reactions for lisinopril such as hypotension (in both lisinopril and furosemide) and cough (in lisinopril). The patient should stand from a lying or sitting position slowly, and there is not current resolution for the cough. ACEIs also have the potential to cause hypersensitivity and renal failure. Any signs of either of these warrants immediate medical attention.
The patient should limit fluid intake and avoid added salts. Additionally, eating a cardiac healthy, low-fat diet enriched in omega-3 fats can help to lower cholesterol.
The patient should monitor his weight and blood pressure daily and keep a log to bring to the next office visit to determine success of the therapy.
(Woo & Robinson, 2016)
If Mr. Russell was an African-American man, the risk for developing a cough or intolerance may be increased with ACEI use. Research has shown that hydralazine with a long-acting nitrate such as isosorbide dinitrate equally effective as ACEI in managing HF in African Americans (Woo & Robinson, 2016). I may prescribe that regimen as an alternative.
Damman, K., Kjekshus, J., Wikstrand, J., Cleland, J. G., Komajda, M., Wedel, H., & Waagstein, F. M. (2016). Loop diuretics, renal function and clinical outcome in patient with heart failure and reduced ejection fraction. European Journal of Heart Failure, 18(3), 328-336. doi:10.1002/ejhf.462
Epocrates. (2019). Lisinopril. Retrieved from Epocrates Website: https://online.epocrates.com/drugs/113410/Prinivil/Monograph
Grundy, S. M., Stone, N. J., Bailey, A. L., Beam, C., Birtcher, K. K., Blumenthal, R. S., & ….Yeboah, J. (2019). 2018 guideline on the managment of blood cholesterol. American College of Cardiology. doi:10.1016/j.jacc.2018.11.003
Woo, T. M., & Robinson, M. V. (2016). Pharmacotherapeutics for advanced practice nurse prescribers (4th ed.). Philadelphia, PA: F. A. Davis Company. Retrieved from https://chamberlain.instructure.com/courses/51073/modules/items/6756223
Yancy, C. W., Jessup, M., Bozkurt, B., Bultler, J., Casey, D. E., Colvin, M. M., & ….Westlake, C. (2017). 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure. Journal of the American College of Cardiology, 70(6), 776-803. doi:10.1016/j.jacc.2017.04.025
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