TRoisieme Respondo

Respond to a minimum of two peers on two separate days. Your responses should be in a well-developed paragraph (300-350 words) to each peer. Integrating an evidence-based resource that is different than the one you used for the initial post.

Respectfully agree and disagree with your peers’ responses and explain your reasoning by including your rationales in your explanation:

Response 1

Heart failure affects approximately 6 million Americans and over 26 million people worldwide (Gupta et. al, 2018). Technological advances and improved medications have decreased mortality and led to increased prevalence of this public health concern. The incidence of heart failure increases with age, with a mortality rate of 50% within 5 years of diagnosis (Woo & Robinson, 2017). The objective assessment of heart failure is classified in four stages A-D, with stage A being the least severe and stage D being the most severe (American Heart Association, 2017). The functional capacity assessment of heart failure is classified stages I-IV; with stage I not causing any physical limitations and stage IV describing the most severe physical limitations (American Heart Association, 2017). Managing the symptomology of heart failure can be complex and requires consideration of the patient’s allergies, medical history, and treatment goals. The purpose of this discussion is to integrate two evidenced-based resources in addition to course textbook in the review of the recommended clinical practice guidelines pertaining to heart failure.

            Stage A objective assessment of heart failure is also known as pre-heart failure or asymptomatic cardiac dysfunction (Morbach et. al, 2020). The American Heart Association (AHA) denotes Stage A heart failure as having no objective evidence of cardiovascular disease or physical activity limitation (2017). Therefore, stage A classification describes a patient possessing common cardiovascular risk factors that lead to the development of coronary artery disease, reduced left ventricular function, and heart failure (Morbach et. al, 2020). Risk factors that contribute to the development of heart disease include but are limited to: hypertension, diabetes, coronary artery disease (CAD), chronic obstructive pulmonary disease, and rheumatic heart disease (Gupta et. al, 2018).  The rational drug choice for this individual given limited health history, would be not to prescribe any medication at this time. Primordial prevention of heart failure would include eliminating ML’s underlying pathologies and inducing relevant lifestyle modifications (Woo & Robinson, 2017).

            Digoxin was once the only successful drug in the treatment of heart failure however, evidenced-based data has suggested it no longer be considered as the primary treatment of heart failure (Woo & Robinson, 2017). ML’s concern of seeing yellow vision or green halos is justified, as it is a sign of digoxin toxicity (Woo & Robinson, 2017). Gender-specific pharmacokinetic differences of digoxin were not found. However, gender related pharmacokinetic characteristics can exist secondary to factors such as body composition, lean muscle mass, and cardiac drugs that bind to plasma protein (Stolarz & Rusch, 2015). Digoxin is still used for patients with systolic dysfunction on optimal doses of beta-blockers, ACE inhibitors, who do not show improvement (Woo & Robinson, 2017). If digoxin is prescribed, therapeutic levels of the drug should be monitored in each patient to prevent toxic effects. The patient’s heart rate, rhythm, renal function and potassium level should also be assessed (Woo & Robinson, 2017). Prescribing digoxin should be considered thoroughly to assure the benefits outweigh the risks.

Response 2

 The American Heart Association (AHA) classifies heart failure (HF) into stages labeled A through D based on severity. Stage A HF patients are asymptomatic but are high risk for becoming HF patients due to other medical conditions such as obesity and hypertension (Tanaka, 2018). Early diagnosis of Stage A HF allows the patient and providers to form a plan to prevent high risk complications and a consequential Stage B through D HF. There are numerous causes for HF. Symptomatic HF are typically caused from improper mechanisms from the left ventricle (King, 2020).

The rational drug choice for treatment for ML is possibly none. ML’s diagnosis of a Stage A HF should be explained to her means that she is at risk but does not have any defect of her heart or symptoms that comprise actual HF. ML will need to be assessed for hypertension, smoking, exercise regimen, diet, and labs should also be ordered such as a lipid panel (Woo & Robinson, 2020). If any of these assessments are positive for a health condition medication may be started but often lifestyle changes are first attempted. If indicated, ML may be started on a diuretic if fluid overload is present or an angiotensin-converting enzyme (ACE) inhibitor as an initial treatment. Digoxin are recommended to be used if diuretics and ACE inhibitors are not successful (Woo & Robinson, 2020). Although digoxin would not be prescribed at this time, ML’s concerns regarding halos can be clarified for her own education as well as in case she needs this medication in the future. A hallucination of green halos around lights is a rare sign of digoxin toxicity (Woo & Robinson, 2020). More commonly patients will experience gastrointestinal sickness, a fast pulse, shortness of breath, and fainting episodes with digoxin toxicity (Cummings, 2020).

There are numerous differences in the use of cardiac medications regarding gender. Females have a higher rate of adverse drug reactions with this class of medication (Kalibala et al., 2020). Body weight as well as fat composition are some factors believed to have an impact in the difference of the pharmacokinetics of medications for females. This leads to more cases of toxicity as well which would result in the need for dose adjustments for females (Kalibala et al., 2020). ACE inhibitors are typically contradicted for women who are pregnant or planning on becoming so due to teratogenic effects (Jackson, 2015). Digoxin has a higher rate of complications and HF mortality despite therapy in women compared to men (Jackson, 2015). Close monitoring of medications for all patients is important but even more so with cardiac medications and with the female population. Monitoring of these possible medications would include functional capacity, fluid status, cardiac rhythm, and labs (Woo & Robinson, 2020). The functional capacity would assess things such as activity of daily living and exercise regimens. Fluids should be checked with all cardiac assessments with weights, listening to the lungs, blood pressures, and edema most commonly. Electrocardiograms regularly with a patient’s cardiologist should also be included with follow-up appointments for any patient on a cardiac medication. Lastly, labs for electrolytes as well as drug levels should be closely monitored. There may be specific tests/monitoring dependent on the medication prescribed as well but these four assessments are recommended by the National Institute for Health and Care Excellence (NICE) as a general rule for patients on cardiac medications for HF (Woo & Robinson, 2020).