The patient, B.J., has stage C heart failure with a functional limitation of stage II based on her symptoms of shortness of breath after physical activity that is relieved by rest. Her pertinent medical history and examination findings support stage C heart failure. She is prescribed lisinopril, spironolactone, metoprolol, atorvastatin, aspirin, and an increased dose of sertraline to treat her heart failure, hypertension, hyperlipidemia, history of myocardial infarction, and depression respectively based on ACC/AHA guidelines.

1. ACC/AHA Guidelines Discussion
Question 1
Heart Failure Stage
The American College of Cardiology (ACC) and American Heart Association (AHA) classify
HF with a four-stage system:
Stage A: High risk of HF but no structural heart disease is present, and patient is asymptomatic
Stage B: Structural heart disease is present, but patient is asymptomatic
Stage C: Structural heart disease is present, and patient is symptomatic
Stage D: Refractory HF, aggressive medical treatment is necessary (Patterson, 2018).
Per the New York Heart Association Classification, Functional Limitations can be described as
below:
Functional Limitations I: None present at this stage
Functional Limitations II: Slight limitations during physical activity, no distress at rest
Functional Limitations III: Marked limitations during physical activity, no distress at rest but less
activity causes symptoms
Functional Limitations VI: Patient tolerates no physical activity, discomfort can occur at rest
(Boyne & et al., 2014).
The patient’s pertinent positives are listed below:
Subjective:
c/o SOB starting 3 months ago
c/o orthopnea
c/o paroxysmal nocturnal dyspnea
States she feels light-headed & faint while going up stairs
Admits to smoking formerly but stopped 20 years ago
Objective:
Overweight with a BMI of 29.8
Lab values show that she has abnormally high lipid panel
+1 pedal pulses bil
2+ pitting edema to knees bil
Inspiratory crackles

2. S4 heart sounds at apex
LVEF: 39%
Systolic murmur
BNP 682pg/mL
The Patient B.J. in the case study is currently in stage C with a functional limitation stage II. My
opinion on her functional limitation is due to the fact the patient becomes SOB after “playing”
with children and is relieved with rest. This task requires more energy and can be expected in
limitation stage II (Boyne et al., 2014). After researching the stages of HF and the reviewing the
pertinent positives the patient is demonstrating symptoms of stage C HF. The patient is no
longer able to perform previous tasks without discomfort and is also experiencing multiple
symptoms of stage C; such as, dyspnea, edema, insp. crackles, fatigue, etc. (Patterson, 2018).
Question 2
Preferred Medications
Angiotensin-converting enzyme inhibitors reduce morbidity and mortality in heart failure
patients with a reduced ejection fraction (Yancy & et al., 2017). The patient also had an elevated
blood pressure of 150/86.
Rx: Zestril (lisinopril) 5 mg
Sig: take one tablet by mouth daily
Disp: 30 (thirty)
Refills: 0 (zero)
(Lisinopril, 2018)
Aldosterone receptor antagonists should be utilized in patients with NYHA class II through IV
heart failure (Armstrong, 2014). The patient has current edema as well as inspiratory crakles. A
diuretic should be prescribed. Per the guidelines, spironolactone was a preferred medication
(Yancy & et al., 2017).
Rx: Spironolactone (aldactone) 12.5 mg
Sig: take one tablet by mouth daily
Disp: 30 (thirty)
Refills: 0 (zero)
(Lasix, 2018)

3. Question 3
Medications prescribed due to history of MI
Beta Blockers reduce mortality by about 30% over one year in patients with Class III or IV
systolic heart failure. Post MI, they can also decrease the likelihood of an irregular heart rhythm
or another heart attack (Yancy & et al., 2017).
Rx: Lopressor (metoprolol) ER 12.5 mg
Sig: take one tablet twice daily
Disp: #60 (sixty)
Refills 0 (zero)
(Metoprolol, 2018)
Additional Mediations
The patient had an elevated lipid profile, demonstrating coronary artery disease. This must be
addressed by lifestyle changes as well as a statin to decrease patient’s risk for another blockage
that could be fatal. Lipitor is an HMG CoA reductase inhibitor and can reduce cholesterol made
by the liver and promote HDL.
RX: Lipitor (atorvastatin) 20 mg
Sig: take one tablet once daily
Disp: # 30 (thirty)
Refills: 0 (zero)
(Atorvastatin, 2018)
Due to the patient’s cardiac history and current lipid profile, I would recommend a baby aspirin
daily. Aspirin is an antiplatelet and can help to decrease blockage and platelet aggregation.
Rx: Aspirin 81 mg
Sig: take one tablet daily
Disp: # 30 (thirty)
Refills: 0 (zero)
(Aspirin, 2018)
The patient scored 22 on her PHQ-9 score, this is indicative of major depression and should be
treated with an SSRI. The patient has been off her psychiatric medications for six months;
however, she was only taking a low dose of sertraline. I will increase her dose and provide three
refills to hopefully increase her likelihood of adhering to the medications

4. Rx: Zoloft (sertraline) 100 mg
Sig: take one tablets by mouth daily.
Disp: # 30 (thirty)
Refills: 3 (three)
(Sertraline, 2018)

5. References
Armstrong, C. (2014). ACCF and AHA Release Guidelines on the Management of Heart
Failure. American Family Physician, 90(3), 186–189. Retrieved from
https://chamberlainuniversity.idm.oclc.org/login?url=https://search.ebscohost.com/login.
aspx?direct=true&db=mdc&AN=25077725&site=eds-live&scope=site
Aspirin. (2019). Epocrates Online. Retrieved from https://online.epocrates.com/
Atorvastatin. (2019). Epocrates Online. Retrieved from https://online.epocrates.com/
Boyne J, Van der Weg K, Uszko-Lencer N, et al. NYHA classification in heart
failure. EUROPEAN JOURNAL OF CARDIOVASCULAR NURSING. 13:S32-S33.
https://chamberlainuniversity.idm.oclc.org/login?url=https://search.ebscohost.com/login.
aspx?direct=true&db=edswsc&AN=000333672200064&site=eds-live&scope=site.
Accessed January 12, 2019.
Lisinopril. (2019). Epocrates Online. Retrieved from https://online.epocrates.com/
Metoprolol. (2019). Epocrates Online. Retrieved from https://online.epocrates.com/
Patterson, K. (2019). Heart Failure Medications: From Stage A to C. MEDSURG Nursing, 27(6),
383–387. Retrieved from
https://chamberlainuniversity.idm.oclc.org/login?url=https://search.ebscohost.com/login.
aspx?direct=true&db=ccm&AN=133645965&site=eds-live&scope=site
Spironolactone. (2019). Epocrates Online. Retrieved from https://online.epocrates.com/
YANCY, C. W. et al. Clinical Practice Guideline: Focused Update: 2017 ACC/AHA/HFSA
Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart
Failure. A Report of the American College of Cardiology/American Heart Association
Task Force on Clinical Practice Guidelines and the Heart Failure Society of
America. Journal of the American College of Cardiology, [s. l.], v. 70, p. 776–803,
2017.
<https://chamberlainuniversity.idm.oclc.org/login?url=https://search.ebscohost.com/login
.aspx?direct=true&db=edselp&AN=S0735109717370870&site=eds-live&scope=site>.
Accessed on: 10 jan. 2019.