Heart Failure Case 1

Mrs Helen Green has been a regular patient at

your community pharmacy. She is currently
being treated for hypertension and her most
recent prescription has been for
bendroflumethiazide 2.5mg daily and
Amlodipine 5mg daily.

Pharmacist: Hello Mrs Green, how are you?

Mrs Green: Well, Ive been to see Dr J and he wanted me to

have some more tests.

She tells you that she has been to the hospital

for some tests since she had noticed that she
has been more breathless than usual and that
her ankles have been swollen.

Pharmacist: What did they find out?

Mrs Green: Apparently my heart isnt working as well as it

should and that I need to go on more tablets

Pharmacist: What are they?

Mrs Green: I dont rally know. I have a new prescription

here and I need to start them now.

Pharmacist: Did they tell you what to do about the tablets

you are already on?

Mrs Green: No. Do you think I need to keep taking them?

Pharmacist: Let me have a look at your new prescription.

She shows you a prescription for:

Furosemide 40mg daily
Enalapril 2.5mg daily
Case 1: Discussion Points

1) What needs to be done about the previous prescription?

The thiazide should be stopped since she is now on a loop

diuretic.
Since both furosemide and enalapril will reduce blood
pressure it is unlikely that she will need the amlodipine as the
dose increases.
She will need her BP monitored as the dose increases and the
amlodipine can be withdrawn and stopped if her BP is OK on
the target dose of enalapril.

2) Comment on the new prescription and Mrs Greens future

medication.

Since she has peripheral oedema she needs a loop diuretic.

The dose of furosemide will depend on the degree of fluid
retention.
She should be started on an ACE inhibitor although the
current dose is somewhat conservative. The dose of enalapril
should be increased over the next few weeks to 10-20mg
twice daily.
The higher dose of enalapril may control the symptoms of
heart failure sufficiently for the furosemide to be stopped.
A beta-blocker should be introduced and up-titrated once she
is on the optimal dose of enalapril.

3) How should Mrs Greens new medication be monitored?

Regular (up to daily) weight, especially if symptoms are

changing.
Renal function and plasma biochemistry should be checked
after each increase in enalapril dose.
BP should be checked at the same time.
These should then be check 6-12 monthly or more frequently
if changes are made to her medication or if her clinical status
changes.
Symptom control and side effects should be assessed at each
visit.

4) What lifestyle changes may Mrs Green have to make?

The usual lifestyle changes are appropriate (diet, exercise,

smoking etc).
In addition her fluid intake should be monitored although a
strict fluid restriction is not required at this stage.
Although salt intake is particularly relevant, she should avoid
salt substitutes.
Heart Failure Case 2

Mrs Green has continued to come to your

community pharmacy since being diagnosed
with heart failure.

Pharmacist: Hello Mrs Green, new prescription?

Mrs Green: Yes, theyve started a new tablet

Her medication now consists of:

Furosemide 40mg daily
Enalapril 10mg twice daily
Bisoprolol 1.25mg daily

Mrs Green: I hope they arent going to start any more

Pharmacist: Well it depends how you get on. They may also
want to increase the strength of some of the
tablets though.
Mrs Green: How will they know what the right strength is?
Pharmacist: We will need to do some tests and this will tell
use whether you are getting the right dose for
you and that there are no serious side effects
Case 2: Discussion points

1) Devise an ongoing monitoring regimen for Mrs Green

In addition to discussion point 3 in the first part of the case,

heart rate should also be checked along with blood pressure.

Once optimal doses are achieved, regular assessment of

symptoms and monitoring for ADRs is required. Plasma
biochemistry, including renal function at least annually, and
ideally 3-6monthly depending on clinical status.

2) What elements of this monitoring regimen do you think it

is feasible for you to do?

No clear answer. May be useful to have general discussion on

what clinical skills pharmacists think they should have, and
practicalities of some of the monitoring, e.g. biochemistry.

3) What elements of this monitoring regimen do you think it

is feasible for her to do?

As 2.

4) Would you make any changes to her medication, and if so,

how?

Apart from further up titration of bisoprolol:

Possible to switch to once daily ACEI if BD inconvenient.
If BP low, can switch to OD ACEI but give at night rather than
am.
Timing of diuretic if a.m. diuresis inconvenient.
Heart Failure Case 3

Mr Jack Hill has been coming to your

community pharmacy for many years. His past
medical history includes angina, type-2 diabetes
and osteoarthritis. Despite this he still manages
to work night-shifts as a security guard in a
local office block.
His current medication consists of:

Aspirin 75mg daily

Simvastatin 40mg daily
Atenolol 25mg twice daily
Avandamet 2mg/1g twice daily
Ramipril 5mg daily
Soluble co-codamol 2 tabs four times a
day
GTN spray as required

Pharmacist: Hello Jack, how are you today

Mr Hill: Well Ive been told that I now have heart failure
to go along with all my other problems although
I dont really know what that means. Ive also
been told that I have to take these water
tablets because I get swollen ankles.

Pharmacist : Yes, I see they have stated you on a tablet

called furosemide. You need to take one of
these each morning.

Mr Hill: The doctor also said something about changing

some of my other medicines, but I cant
remember what he said. Do you think they are
going to start more, or change the ones Im on?

Pharmacist: That will depend on a number of things. It

really depends on how your responding the
medicines we have you on already.
Case 3: Discussion points

1. What further changes may need to be made to Jacks

medication?

Increase dose of ramipril to BD or 10mg OD assuming BP OK,

renal function OK and no previous ADRs.
Review choice of oral antdiabetic agent since rosiglitazone
causes fluid retention (metformin OK though).
? Discuss choice of BB. Atenolol not licensed in CHF but if
dose OK (HR controlled) then no need to change
Choice of analgesic formulation due to Na content of soluble
co-codamol (Paracodol 2 QID contains 146mmol Na,
equivalent to 8.5g salt).

2. What additional information would be useful to help make

decisions about Jacks future medication needs?

Need to know BP and HR before deciding of dose changes to

BB.
Need to know BP and renal function / K before deciding of
dose changes to ACEI.
Any previous ADRs at higher doses.
How good is his glycaemic control.
Does he have to use his GTN spray often?
How good is his pain control?
If he remains symptomatic despite optimal BB and ACEI, may
have to consider adding an ARB

3. What factors may affect the design of his medication

regimen?

In addition to potential poor adherence to his regimen, what

is the impact of him working night-shift?
Switch am and pm med around?
Take diuretic in the evening?
Heart Failure Case 4

Mrs Jean McDonald has a long history of heart failure resulting from
a myocardial infarction 8 years ago. In addition to being cared for
by one of the local GPs, she also attends a heart failure clinic at the
local hospital.

She is currently on:

Furosemide 120mg daily

Enalapril 20mg twice daily
Carvedilol 12.5mg twice daily
Slow K 1 tab three times a day
Aspirin 75mg daily
Simvastatin 40mg twice daily

Pharmacist Hello Mrs McDonald, how did you appointment

at the clinic go?
Mrs McDonald Well as you know Ive been getting a lot more
breathless recently and my legs are more
swollen than usual. When they checked me out
they also thought that I had some fluid in my
lungs.
Pharmacist What are they planning to do?
Mrs McDonald Well Ive been told to increase the number of
water tablets I take to four a day for now and
see how I get on.

Case 4: Discussion point

What advice can you give Mrs McDonald regarding the

increased dose of diuretic?

May be better to split dose (80mg am, 80mg about 2pm).

Go back to GP or clinic if no weight loss, or improvement in
symptoms / peripheral oedema.
Has she an appointment to have renal function checked?
How much fluid is she taking a day? At this stage a 1.5-2L
fluid restriction would be appropriate.
Later that week Mrs McDonald comes in to your Pharmacy
again.

Pharmacist Hello Mrs McDonald, how are you getting on

with the extra water tablet?
Mrs McDonald Not so bad, but my ankles dont seem to be
going down.
Pharmacist Hows your breathing?
Mrs McDonald Well I find it a bit more difficult to do things and
Im not sleeping as well as I usually do.
Pharmacist Have you spoken to anyone at the clinic about
what to do?
Mrs McDonald No, but I have another appointment in 2 week.

Case 4: Discussion point

What advice would you give Mrs McDonald?

Need earlier appointment (this week).

Check compliance with fluid restriction
Has she been taking the extra tablet?
The next day Mrs McDonald comes back to your Pharmacy
with a new prescription.

Pharmacist Hello Mrs McDonald, did you get in touch with

someone at the clinic?
Mrs McDonald Yes. They spoke to Dr Young and got him to
start a new tablet.
Pharmacist Did they tell you what it is?
Mrs McDonald They did tell me but it was such a long name
that I cant remember. Ive got the prescription
here.

Case 4: Discussion points

1. What are the possible options for the new medicine?

A number of addition medicines can be added when a patient

remains symptomatic on otherwise optimal therapy (her BB is
below target but this would not be increased while she
remains poorly controlled, assuming that this is not the
maximum tolerated dose anyway!)

A thiazide diuretic could be added to overcome potential loop

diuretic resistance.

Spronolactone to antagonise the fluid retaining effects of

aldosterone.

Candesartan, to further block the remain-angiotensin-

aldosterone pathway.

The addition of a thiazide is most likely at this stage.

2. For each of the options, what are:

a. The likely doses
b. The ongoing monitoring
c. The length of treatment

Thiazide: bendroflumethiazide or metolazone, 2.5mg either

daily or on alternate days. Frequency can be as low as weekly
or as required. May go up to 5mg if no response. Metolazone
probably more potent. Duration dependant on time it takes to
shift fluid.

Spironolactone 25mg daily, probably indefinitely, although it

can be reviewed if marked improvement in symptoms.
 Candesartan, up titrated to 32md daily if tolerated. Probably
indefinite

3. For each of the options, what advice would you offer Mrs
McDonald?

Thiazide: Significant diuresis is possible. Need to have

frequent checks on renal function / K. May need more Slow
K

Spironolactone: GI disturbance possible, Other side effects

less common. Need to have regular checks on renal
function / K. May need to stop Slow K.

Candesartan: Need to have regular checks on renal

function / K. May need to stop Slow K

For all: Risk of symptomatic hypotension (postural

dizziness) educate on how to minimise effect.

PS. Why is her simvastatin BD? Mistake? Even if meant to be 80mg

a day, probably better to switch to more potent drug, e.g.
atorvastatin Dont forget to review other, non-CHF, meds.