Here are the key points to discuss with the patient about potential adverse effects of carvedilol: - Common side effects when starting or increasing the dose include dizziness, fatigue, shortness of breath, and chest pain. These are usually mild and temporary. - Let the doctor know immediately about any chest pain, as this could be a sign of a serious problem. Rest and notify the doctor of any other concerning symptoms. - The doctor may start at a low dose and slowly increase the dose over weeks to allow the body time to adjust and minimize side effects. - Drink plenty of water and follow a low-sodium diet to prevent fluid retention, which can worsen symptoms. - Contact the

1. CARDIOVASCULAR
DISORDERSHeart Failure : Systolic Dysfunction
|

2. HISTORY TAKING
Name: RICHARD ANDERSON
Age : 65 year old
Sex : MALE
Nationality : AFRICAN-AMERICAN
Occupation : RETIRED MUSICIAN

3. CHIEF COMPLAINT “ I think I might have the
flu. I have been feeling run down,
and I haven’t been able to get up
the stairs to my bedroom
because I get winded. ”

4. HISTORY OF PRESENT ILLNESS
Richard Anderson is a 65-year-old African American man who was
brought to the ED by ambulance upon request of his
endocrinologist. The patient had called the physician’s office this
morning to cancel his routine visit for diabetes follow-up because he became short
of breath and diaphoretic after attempting to climb a flight of stairs. When evaluated
by the paramedics in his home, the diaphoresis had resolved, and his heart rate
was in the range of 100–120 bpm. The patient states that he has been gaining
weight and having progressively worsening dyspnea on exertion over the last 5
days. His shortness of breath is often worse at night, forcing him to “sit bolt
upright.” He began sleeping in his recliner about 3 days ago. He is unable to
complete physical activities that he could do 2 weeks ago without difficulty.

5. PAST MEDICAL HISTORY
Type 2 DM × 15 years, untreated until 3 years ago; neuropathy ×
2 years and retinopathy × 1 year
HTN × 20 years
Hypercholesterolemia (documented 6 months ago)
CVA × 2 (2 and 3 years ago)
Recurrent TIAs × 1 year

6. FAMILY HISTORY
Father died at age 65
of a heart attack.
Mother died in her
70’s in an MVA.
One brother age 70
alive with DM.

7. PERSONAL AND SOCIAL HISTORY
Retired musician living alone. Prior to his
CVAs, his hobby was repairing and playing antique
pump organs. He has a 30 pack-year history of
smoking but reports quitting 22 years ago. He has a
positive history for alcohol use but states he “hasn’t
had a drop in 12 years.

8.  Rosiglitazone 4 mg po once daily
 Metformin XR 1,000 mg po once daily
 Glyburide 5 mg po BID
 Atorvastatin 20 mg po once daily (LDL 90 mg/dL 1 month ago)
 Lisinopril 10 mg po once daily
 Aspirin/extended-release dipyridamole 25 mg/200 mg po twice daily
CURRENT MEDICATION TREATMENT

9. REVIEW OF SYSTEMS
Reports having headaches recently, but nothing that he
would consider unusual or out of the ordinary. Denies any recent
chest pain. No chronic cough, but has had recent episodes of
coughing spells without productivity. Complains of recent
abdominal bloating and of being awakened the past four evenings
to relieve his bladder. He reports some weakness in his right lower
extremity but states that it is unchanged from his most recent
stroke. He denies chronic joint pain.

10. General
The patient is sitting up on the gurney in the ED in moderate distress.
VS
BP 150/95, P 100–120, RR 22, T 35°C; Wt 103 kg (usual weight 93kg), Ht 5'11''
Skin
Color pale and diaphoretic; no unusual lesions noted

11. Review of Systems
HEENT
PERRLA, EOMI, fundi were not examined. He has a complete upper denture and
about two-thirds of the teeth in the lower jaw are remaining and are in fair repair.
Neck
(+) JVD at 30° (8 cm). Carotid bruit is not appreciated. No lymphadenopathy or
thyromegaly.
Lungs/Thorax
Respirations are even. There are fine crackles in both lung fields posteriorly noted
two-thirds of the way up the lung fields. No CVAT.

12. Review of Systems
ECG
Sinus tachycardia rate of 112, QRS
0.08. Diffuse non-specific ST-T
wave changes. Low voltage
Chest X-Ray
PA and lateral views show
evidence of congestive heart failure
with cardiomegaly, interstitial
edema, and some early alveolar
edema. There is a small right
pleural effusion.

13. Heart
Regular rhythm, no rubs, variation in intensity of S1 as expected. S3 is
appreciated at apex in lateral position. PMI displaced laterally and
difficult to discern.
Abd
Soft, NT/ND, (+) HJR, liver and spleen slightly enlarged, no masses,
hypoactive bowel sounds

14. Clinical Course (2D-Echo)
Result showed severe left ventricular dilation and increased left atrial
dimension, akinesia of the septum and severe LV dysfunction. EF was
estimated to be 15-20%, with no visible clots.

15. Review of Systems
Genit/Rect
Guaiac (–), genital examination not performed
MS/Ext
3+ pitting pedal edema bilaterally; radial and pedal pulses are of poor intensity
bilaterally; grip strength greater on left than on right
Neuro
A & O × 3, CNs intact. Some sensory loss in both LE below the knee.
DTR 1+

16. LABORATORY FINDINGS
Na 139 mEq/L 136 - 145 Normal
K 3.4 mEq/L 3.6 - 5.2 Low
Cl 99 mEq/L 100 - 108 Low
(Borderline
)
Mg 1.2 mEq/L 1.5 - 2.5 Low
Ca 8.8 mg/dL 2.2 - 2.62 High
Hgb 126 g/L 120 -180 Normal
Hct 39.5% 37 - 54% Normal
Plt 339 ×
103/mm3
150,000 -
450,000
mm3
Normal
WBC 8.6 ×
103/mm3
4-
11x10^9/L Normal
PMNs 70% 50 - 70% Normal
Lymphs 23% 20-44% Normal
Monos 7% 2 - 9 % Normal
PT 20.6 sec 12 - 15 sec Long
INR 2.8 1 High
TSH 1.42 mIU/L 0.25 - 5 Normal

17. CO2 27 mEq/L 24 - 30 meq/L Normal
BUN 20 mg/dL 7 - 20 mg/dL Normal
SCr 1.8 mg/dL 0.7 - 1.3 mg/dL HIgh
Glucose 7.7 mmol/L 3.9 - 6.1 High
BNP 1,200 pg/mL <400 pg/mL High
Troponin I 1.8 ng/mL <0.01 ng/mL High
AST 36 IU/L 15 - 37 Normal
ALT 43 IU/L 30 - 65 Normal
Alk phos 150 IU/L 20 - 130 IU/L High
GGT 37 IU/L 10-55 IU/L Normal
T. bili 0.2 mg/dL 0.2 - 1.2 mg/dL Normal (Borderline)
CK 20 IU/L 21 - 232 IU/L Normal
CK-MB 0.8 IU/L 0.00 - 6.0 IU/L Normal
A1C 6.9% <6.5& HIgh

18. PHYSICAL EXAMINATION AT THE ER
PATIENT PROBLEM LIST
Stage 1 Hypertension
Class 1 Obesity
Liver and Spleen Enlarge
Peripheral Edema
Hypokalemia
Hypercalcemia
Hypomagnesemia (possible Renal
failure)
DIET
Low fat salt diet
Controlled water intake

19. DISEASE
Diabetic patient with new-
onset congestive heart
failure

20. Congestive heart failure (CHF) is a chronic progressive
condition that affects the pumping power of your heart
muscles.
While often referred to simply as “heart failure,” CHF
specifically refers to the stage in which fluid builds up
around the heart and causes it to pump inefficiently.
CHF develops when your ventricles can’t pump blood in
sufficient volume to the body. Eventually, blood and other
fluids can back up inside your:
- lungs
- abdomen
- liver
- lower body

21. TAKE HOME MEDICATIONS
He was discharged on :
 lisinopril 20 mg po daily
 carvedilol 6.25 mg po BID
 furosemide 40 mg po daily
 potassium chloride 40 mEq po daily
 magnesium oxide 400 mg po daily
 insulin glargine 20 units SC hs
 aspart insulin 5 units SC AC
 clopidogrel 75 mg po daily
 aspirin 325 mg po daily
 atorvastatin 40 mg po daily

22. QUESTIONS

23. PROBLEM IDENTIFICATION

24. 1. a. List of this patient's drug - related problems
• Carvedilol + Furosemide
• Carvedilol increases potassium and Furosemide decreases
potassium.
• KCl + Furosemide
• Both decreases serum potassium
• KCl + Carvedilol
• Both increases serum potassium
• Lisinopril + Insulin Glargine
• Lisinopril increases the effects of insulin glargine (Hypoglycemia)

25. 1. a. List of this patient's drug - related problems
• Lisinopril + Insulin Aspart
• Lisinopril increases the effects of insulin aspart (Hypoglycemia)
• Aspirin + Insulin Glargine/Aspart
• Aspirin increases effects of insulin (Hypoglycemia)
• Aspirin + Lisinopril (Serious)
• Coadministration may result in significant decrease
in renal function. NSAIDs may decrease the antihypertensive effect of
ACE inhibitors.
• Aspirin + Clopidogrel
• Either increases toxicity of the other.

26. 1.b. What signs, symptoms, and other information indicate the presence and severity of the
patient’s heart failure?
• Interstitial and alveolar edema.
• Indication of Cardiomegaly.
• Severe LV dilation and increased left atrial dimension.
• Presence of Peripheral edema (Lower Extremeties).
• Patient's Hypokalemia and Hypomagnesemia with
Hypercalcemia.
• Transient TIA's leading to stroke.
• Enlargement of spleen and liver.

27. 1.c. What is the classification and staging of heart failure for thispatient upon presentation?
• STAGE C

28. 1.d. Could any of this patient’s problems have been caused by drug therapy?
• The severity of the patient's
hypertension can be traced back to
the drug-drug interaction of lisinopril
and aspirin.
Reason: Aspirin + Lisinopril
(Serious)
Coadministration may result in
significant decrease in renal
function. NSAIDs may decrease
the antihypertensive effect of ACE
inhibitors.
• The patient's hypokalemia caused by
the interaction of KCl and furosemide.
• Weight gain maybe attributed to the
patient's use of Atorvastatin.
• Coughing can be caused by the use of
ACE inhibitors (Lisinopril)
• Aspirin can contribute to patient's
abdominal bloating.

29. DESIRED OUTCOME

30. 2.a. What are the goals for the pharmacologic management of heart failure in this patient?
The primary goal of therapy is to treat the patient's predisposing factors/conditions
such as (poorly managed DM, severe hypertension and hyperlipidemia).
• Manage the patient's severe hypertension by discontinuing the use of ACE inhibitor
(lisinopril) and substituting it with another antihypertensive drug such as ARB's and CCB's.
(GOAL: Lower the blood pressure to decrease risk of another CV.)
• Increased dose of atorvastatin to manage the patient's hypercholesterolemia. (Lower the
LDL and increase HDL of the patient.)
• Manage DM by administering insulin preparations to lower the patient's blood glucose
level.

31. 2.b. Considering his other medical problems, what other treatment goals should be
established?
Non-pharmacologic interventions:
Diet:
• Saturated fat should be limited to 10% of total daily calories.
• Fat-free and low fat dairy products, cereal and grain products.
• Inducing a weight loss of 10%.
• Include moderate sodium restriction
• Successful intervention to the modifiable risks such as obesity.
Normalize blood pressure with continous monitoring.
Encourage the patient's significant others to help him with his diet
regimen or exercises and update you of any progress and or
complaints.

32. THERAPEUTIC ALTERNATIVES

33. Since the patient is classified to have Stage C Heart Failure, meds should
include:
• Aldosterone receptor antagonist such as Aldactone (25mg PO q12hr)
• Angiotensin Receptor blockers such as Losartan (50mg PO OD)
• Beta blocker such as carvedilol (6.25mg PO BID)
• Switch atorvastatin with a bile acid sequesterant to reduce the risk of weight
gain caused by atorvastatin. Ex: Colestipol 2g PO qDay.
• Aspirin 325mg PO daily
• Administer insulin aspart 5 units SQ AC and insuline glargine 20 units SC HS.
3. What medications are indicated in the long-term management of this patient’s heart failure
based upon his stage of heart failure?

34. OPTIMAL PLAN

35. 4. What drugs, doses, schedules, and duration are best suited for the management of this
patient?
Drugs Doses Schedules Duration
Aldactone 25mg PO q12hr (8am-8pm) 17 months
Losartan 50mg PO OD (9am) 15 months (monitor BP)
Carvedilol 25mg PO BID (8am-8pm) 15 months (monitor BP)
Colestipol 2g PO OD (7am) 2 months (monitor lipid
levels)
Aspirin 325mg PO OD 3 weeks(Monitor INR
and PT)
Insulin aspart 5 units SQ 20 mins after meals until DM is fully
managed (or as
prescribed by physician)
Insulin glargine 20 units SQ at bed time until DM is fully
managed (or as
prescribed by physician)

36. OUTCOME EVALUATION

37. 5. What clinical and laboratory parameters are needed to evaluate the therapy for
achievement of the desired therapeutic outcome and to detect and prevent adverse events?
Hypertension:
Blood pressure monitoring
Cardiovascular accident:
Troponin I
CK
Hypercholesterolemia:
Total Cholesterol
LDL and HDL levels
Triglycerides
DM:
Blood Glucose levels
Peripheral Edema:
Edema Scoring

38. PATIENT EDUCATION
6. What information should beprovided to the patient about the medications used to treat
his heart failure?
• Aldactone (25mg PO q12hr)
• May cause gynecomastia in men.
• Losartan (50mg PO OD)
• Avoid taking grapefruit juice.
• Carvedilol (6.25mg PO BID)
• Best to take carvedilol on a full
stomach. (Taken with food)
• Colestipol 2g PO qDay.
• Taken with food.
• Aspirin 325mg PO daily
• Avoid eating green leafy vegetables.
• Insulin aspart
• educate the patient on how to
administer doses of insulin via
subcutaneous route.
• abdominal region, buttocks, thigh,
or upper arm are the routes to
administer insulin through a 45 to
90⁰ angle.
• Do not use the same syringe and
site when administering doses.
• Monitor for possible hypoglycemia.

39. FOLLOW-UP QUESTIONS

40. 1. What is the role of routine monitoring of BNP levels in the management of this patient’s
heart failure?
Brain natriuretic peptide (BNP) levels are simple and
objective measures of cardiac function. These measurements
can be used to diagnose heart failure, including diastolic
dysfunction, and using them has been shown to save money in
the emergency department setting. The high negative predictive
value of BNP tests is particularly helpful for ruling out heart
failure.

41. 2. The patient’s development of worsening symptoms may be a result of initiation of carvedilol
therapy. Outline information that should be provided to the patient about common adverse
effects when initiating or titrating carvedilol therapy. Describe how they should be managed if
they occur.
• Chest Pain may be attributed to the use of carvidelol:
If this happens, do not discontinue immediately. Titrate dose
before stopping.
• Fatigue may be a side effect of carvedilol:
If this happens, get enough rest. Ask your doctor if you can adjust your
medication time and dose.
• Stomach problems:
Take carvedilol on a full stomach as taking it with an empty
stomach will trigger stomach problems such as bloating.

42. 3. Outline a therapeutic plan for transitioning this patient from carvedilol immediate release
to the controlled release product.
Elderly patients (> 65 years of age): When switching from higher doses of
immediate-release carvedilol to COREG Controlled release, a lower starting dose
should be considered to reduce the risk of hypotension and syncope.