C155_Task1

docx

School

Riverside City College *

*We aren’t endorsed by this school

Course

C155

Subject

Medicine

Date

Apr 3, 2024

Type

docx

Pages

Uploaded by AmbassadorCatMaster30

Running head: HEART FAILURE PATHOPHARMACOLOGY 1 C155 Task 1: Heart Failure Pathopharmacology

HEART FAILURE PATHOPHARMACOLOGY 2 C155 Task 1: Heart Failure Pathopharmacology Patients with heart failure (HF) have a variety of options to manage their illness. The most common treatments involve drugs that moderate the cardiovascular system and reduce the likelihood of heart attack. HF affects more than 6 million adults in the United States, and caused 379,800 deaths (13.4% of the total) in 2018 (U.S. Department of Health & Human Services, 2020). Over 550,000 new cases of HF occur in the US each year (Cleveland Clinic, 2021). Heart disease is the leading cause of death in California, and caused 62,797 (23.4% of the total) deaths in 2017 (American Heart Association, 2017). Treatment for heart failure involves medication, dietary changes and adjustments to physical activity. Though treatable in some respects, HF is a serious chronic illness that seriously impacts patient health and can lead to death. Heart Failure Disease Process Heart failure, also known as congestive heart failure (CHF), is defined as reduced efficiency of the heart muscle leading to ineffective pumping of the blood. Together, the heart and lungs form the cardiopulmonary system, which delivers oxygenated blood to body tissues and recirculates deoxygenated blood back through the lungs. With HF, the heart is either too weak to pump blood effectively or too stiff to fill properly with blood (and some patients exhibit both conditions) (NHLBI, 2021). HF can be differentiated from a heart attack (myocardial infarction) as it is a chronic, rather than acute, condition. HF progression can be staged in four stages from A (risk for HF) to D (advanced HF) and its severity can be classified from I (low impact) to I V (severe impact) in terms of impact on a patient’s physical activities (Cleveland Clinic, 2021). Ejection fraction is a measure of how much blood the heart’s ventricle can pump in a single contraction, and is calculated by dividing stroke volume by end-diastolic volume and multiplying by 100. In some patients, ejection fraction may be preserved, but HF generally

HEART FAILURE PATHOPHARMACOLOGY 3 demonstrates diminished ejection fraction, as the heart’s left ventricle is unable to pump blood at full capacity. An ejection fraction of 55%-75% is normal, 40-54% is subnormal, 35%-39% is considered heart failure with reduced ejection fraction, and below 35% is considered moderate to severe heart failure (Cleveland Clinic, 2021). The two main types of heart failure are differentiated according to whether ejection fraction is preserved. Pathophysiology HF has a number of underlying causes and contributing factors, including: genetics, age, diet, tobacco use, alcohol use, high blood pressure, fluid imbalance, vascular disease, kidney disease, lung disease, diabetes, obesity, and sleep apnea (Dharmarajan & Rich, 2017; McCance & Huether, 2018). Recent research suggests a link between immune activation, inflammation, and cardiac illness. Older adults are at greater risk for left ventricular hypertrophy (enlargement) and fibrosis (thickening) of the heart regardless of their blood pressure levels (McCance & Huether, 2018, ch. 32). Structurally, the heart wall consists of three layers, the largest of which is the myocardium, or heart muscle, composed of cardiomyocytes, the heart muscle cells (McCance & Huether, 2018, ch. 32). The thickness of the heart wall varies due to the pressure and resistance within each chamber. Normal pressure values for the heart chambers show a mean pressure of 4 mmHg for the right atrium, 24 mmHg systolic and 4 mmHg end-diastolic for the right ventricle, 7 mmHg for the left atrium, and 130 mmHg systolic and 7 mmHg end-diastolic for the left ventricle. If blood pressure levels are too high or low compared to normal limits, it can be a sign of HF. Any structural changes in thickness, size, or stiffness of the heart chambers are a sign of HF. There are four valves within the heart, divided into semilunar (pulmonary and aortic) and atrioventricular (mitral and tricuspid). Damage to these valves and their accompanying structures

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

HEART FAILURE PATHOPHARMACOLOGY 4 can result in HF, and valve function may worsen as a result of an impaired cardiovascular system (McCance & Huether, 2018, ch. 32). The heart muscle itself is highly vascular, and if it increases in size due to heart failure, the arteries and capillaries that supply it with blood are impacted, and unable to properly perfuse the heart tissues with oxygen (McCance & Huether, 2018, ch. 32). When a patient begins to experience HF, the heart muscle fibers stretch and undergo damage, which can be measured through the detection of Troponin T and troponin I in the bloodstream. The protein titin is involved in the springiness or stiffness of the muscle tissue, and stiff cardiac tissue is a sign of HF (McCance & Huether, 2018, ch. 32). Within the vascular system, HF can cause diminished release of nitric oxide and issues with the endothelial integrity of the blood vessels. Stenosis, or narrowing, of a vessel or other pathway in the body, can contribute to HF. Critical indicators for HF include: decreased cardiac output and index, decreased stroke volume and index, decreased mean arterial pressure, and increased pulmonary vascular resistance (McCance & Huether, 2018, ch. 32). As the heart becomes weaker, stiffer, or enlarged over time, it can no longer supply an adequate amount of oxygenated blood to vital organs. Unsafe blood pressure levels and lack of oxygen perfusion can impact the extremities, lungs, kidney, eyes, and brain. Myocardial infarction (heart attack) results as a lack of oxygenation of the heart itself, and will generally result in systemic organ failure and death if not immediately treated. HF may cause a buildup of fluid in the lungs and a feeling of being unable to breathe. The symptoms of heart failure include shortness of breath, an ability to complete physical activity, angina (chest pain), pain or tingling in the extremities, dizziness, and arrythmia (altered heartbeat). Ultimately, HF can be a result of many different factors that are individual to each patient, but regardless of the cause, unmanaged HF will lead to serious health issues and death. Mortality rates for HF are high, estimated at around 20% at one year after diagnosis and 50% at

HEART FAILURE PATHOPHARMACOLOGY 5 five years after diagnosis, with lower mortality rates for patients 60 years and younger (Dharmarajan & Rich, 2017). Standard of Practice Clinical Practice Guidelines for the diagnosis and treatment of HF are available from a number of international, national, and state resources. The 2017 American College of Cardiology/American Heart Association Heart Failure Society of America (ACC/AHA/HFS) update to the 2013 ACCF/AHA Guidelines for the Management of Heart Failure provides a comprehensive guide to the management of this illness (Yancy et al., 2017; 2019). These guidelines are routinely updated with the latest evidence from the field. As with any chronic illness, patient education and lifestyle changes are central to the management of HF. Following the process of assessment, diagnosis, intervention, and evaluation, HF may be properly detected and treated through a combination of medications and other targeted interventions such as implantable medical devices, surgery, and heart transplants. An assessment that asks about personal and family history of heart disease and includes blood work that tests for abnormal lab values will begin the process of detecting HF in a patient presenting concerning symptoms. Two important biomarkers for detecting HF are “BNP (B-type natriuretic peptide) and NT-proBNP (N-terminal pro-B-type natriuretic peptide)” (Yancy et al., 2017, p. 780). In more severe cases, other biomarkers may be used to detect injury or fibrosis of the heart muscle (Yancy et al., 2017). A chest X-ray, MRI, or CT scan can show enlargement, narrowing, fibrosis, or other structural changes to the heart and blood vessels. An angiogram is another specialized imaging technique that uses fluorescent dye to image blood flow throughout the cardiovascular system, revealing any restricted blood flow, clots, or leakage (McCance & Huether, 2018, ch. 36). Physical stress tests and 24-hour monitoring may be carried out while the

HEART FAILURE PATHOPHARMACOLOGY 6 patient wears a Holter monitor that records the electrical activity of the heart. An electrocardiogram records any issues with the heart’s rhythm. An echocardiogram is a specialized imaging technique for measuring the heart that can detect small, subtle changes (McCance & Huether, 2018, ch. 34). Generally, less extensive assessments, such as lab tests, that indicate potential HF will be confirmed by following up with additional imaging and more intensive forms of screening. The patient’s disease will be staged according to the NYHA class system. Once HF is confirmed and other potential diagnoses are ruled out, it is important to begin treatment immediately. The primary way to treat HF is through medications that block harmful chemical signals that could cause a heart attack, such as Angiotensin-converting enzyme (ACE) Inhibitors or Angiotensin receptor blockers (ARBs). Other medications, such as statins, help to regulate cholesterol, while vasodilators and blood thinners may help to lower blood pressure and reduce the incidence of clotting (Arnett et al., 2019). African-Americans may require a different regimen of medications than Non-African-American patients, such as the combination of hydralazine and isosorbide dinitrate (Ziaeian, Fonarow, & Heidenreich, 2017). Diuretics and other medications help to maintain electrolyte and fluid balance. Specialized medications such as Digoxin can help to maintain proper heart rhythm, which can also be assisted by implantable electronic devices. The intention of these medications is not to cure HF or fully restore function to the heart, but to lessen the worsening of symptoms, avoid heart attacks or other serious cardiovascular events, to maintain quality of life, and to retain the ability to complete daily physical tasks. Patient education is extremely important to ensure compliance with and proper use of these potentially lifesaving medications.

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

HEART FAILURE PATHOPHARMACOLOGY 7 Pharmacological Treatments As a large, populated, and developed state, California has wide access to pharmacies, medical clinics, and hospitals that can assist with the management of HF. California has more pharmacies than any state in the US, over 8,000 (IQVIA, 2019). In Riverside County, many pharmacies are located within a reasonable distance from the city center, while medical transport and public transport provide options for HF patients to see their pharmacists and get their medications safely. Californians rank better than the national average when it comes to heart health, but some populations, such as the rural and suburban poor, have worse health outcomes than the state or national averages. The state’s resources are concentrated in the wealthy areas of Los Angeles and San Francisco, and there are major health disparities between different groups: the wealthy and poor, the employed and unemployed, the insured and uninsured. In Riverside County, patients may be limited in terms of medication access and demonstrate lower rates of medication compliance due to lower income, lack of insurance coverage, lack of education, and other demographic factors. There is a higher rate of death due to coronary heart disease in Riverside County (105.7 per 100,000) compared to state (85.1 per 100,000 or national averages (92.7 per 100,000), though it has decreased over the past decade (SHAPE Riverside, 2021). In Southern California, Riverside, San Bernardino and Imperial counties have a limited amount of primary care physicians and specialists compared to their population, a situation mirrored in the Central Valley and Far Northern California counties. Riverside County has an estimated 31 primary care physicians and 55 specialists per 100,000 people, which is far lower than the Los Angeles or San Francisco Bay areas (Gaines, 2017). The lack of primary care providers means less screening and prevention of HF, while a lack of specialists (including cardiac specialists) can lead to poorly managed care.

HEART FAILURE PATHOPHARMACOLOGY 8 There is a set regimen of medications that are used in the treatment of HF, but the exact medications and dosages used will depend on the individual patient and his or her disease process and background. ACE inhibitors are broadly recommended for patients who will respond to them, depending on the patient’s individual background and type of HF. An ARB medication may be combined with a neprilysin inhibitor (NI). Patients that do not respond to, or cannot tolerate the medications initially prescribed may be prescribed alternatives. However, patients with reduced ejection fraction and moderate to severe illness should consider ARNI (Yancy et al., 2017). ARNI medications do pose the risk of hypotension and angioedema. These medications should be combined with beta blockers, which help to control blood pressure and regulate heartbeat, and aldosterone antagonists, which also help to regulate blood pressure, for certain patients (Yancy et al., 2017). Vasodilators including hydralazine and various nitrates are also used to manage a patient’s hypertension. Digoxin may be used to treat heart rate and regulate electrolyte balance. Blood thinners and diuretic medications may be used to regulate clotting, blood pressure, and fluid balance. Certain groups of patients, such as African-Americans, may not respond well to medications like ACE inhibitors. They may need different medications or dosages than non-African-Americans. A targeted treatment plan that includes patient education and a holistic approach to managing HF is key. The overall goal of pharmacological intervention in HF is to ensure that the patient’s blood pressure remains stable, to suppress inflammation of the heart tissue, to ensure oxygen perfusion, to regulate the heart’s rhythm, to keep fluids and electrolytes in balance, to prevent heart attacks, and, ultimately, to allow the patient to conduct the functions of daily life while avoiding further harm or mortality.

HEART FAILURE PATHOPHARMACOLOGY 9 Clinical Guidelines California providers, such as major insurer Blue Shield, follow the national practice guidelines set forth by the AHA/ACC/HRS (Blue Shield of California, 2021). Assessment is conducted through taking a patient background and vital signs and conducting blood biomarker tests. Diagnosis is confirmed through additional testing and imaging. Blue Shield uses stages A through D to categorize patients who are at-risk for heart failure and who have moderate to advanced heart failure. Each stage includes therapeutic goals along with drugs and other potential interventions such as implantable devices and surgery. The guidelines for Blue Shield of California outline general measures for management of HF: control blood pressure, smoking, diet, and alcohol intake; monitor fluids and sodium; vaccinations; control atrial fibrillation and\or tachycardia; blood thinners; coronary revascularization; avoiding medications that have potential negative interactions; implantable cardioverter defibrillator; thyroid testing (Blue Shield of California, 2021). Further interventions are divided between patients with preserved ejection fraction and those with end-stage heart failure and accord directly with national standards (Blue Shield of California, 2021). End-of-life care and transplant should be considered for advanced heart failure patients. Clinical Guidelines for Assessment Patients may seek care at a clinic or emergency room for HF symptoms such as shortness of breath, chest pain, rapid heartbeat, pain or tingling in the extremities or other concerning symptoms. Emergency departments have a triage process for rapidly assessing patients who may be experiencing HF or having a heart attack. Primary care providers screen for HF in at-risk patients as part of routine physicals and check-ups. In the past, assessment and diagnosis of HF relied upon a variety of assessments and imaging techniques, and less upon the use of laboratory

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

HEART FAILURE PATHOPHARMACOLOGY 10 biomarker tests, which now form a key component of assessing damage to the cardiovascular system (Yancy et al., 2017). Current clinical practice guidelines call for “a careful history and physical examination including assessment of risk factors, symptoms, vital signs, level of consciousness, mucous membrane color, and cardiopulmonary functioning” (McCance & Huether, 2018, ch. 32). Taking vital signs including O2, blood pressure, pulse, and peripheral pulse can help to assess for impaired heart function. An initial assessment for HF risk factors, signs, and symptoms should be followed by additional tests to confirm the diagnosis. Clinical Guidelines for Diagnosis There is no single diagnostic test for HF (Yancy et al., 2017). The Heart Failure Association, American College of Cardiology & American Heart Association, and the Heart Failure Society of America all provide diagnostic guidelines for a definitive diagnosis of HF (Crespo‐Leiro et al., 2018). Signs and symptoms of apparent HF can also occur as a result of other illnesses. Following the initial assessment, clinicians should perform a thorough physical examination, including listening to heart and lung sounds and ordering additional tests as needed. A chest X-ray should be ordered to examine the size of the heart and condition of the lungs. SPECT or other radiotracer imaging techniques can assist to diagnose HF. An electrocardiogram and stress testing or 24-hour monitoring with a Holter monitor can help to detect issues with “impulse generation or conduction” in the central nervous system and the nodes of the heart (McCance & Huether, 2018, ch. 32). An echocardiogram can further confirm HF by providing detailed images of the structure and performance of the heart. If an echocardiogram provides insufficient detail, use of radiographic imaging and MRI can be useful. Cardiac catheterization can directly measure the oxygenation and blood pressure within the heart, and can be used in conjunction with radiographic dye to provide high quality imaging. HF manifests not only in the

HEART FAILURE PATHOPHARMACOLOGY 11 heart itself, but in the vascular tissues of the entire body. Investigating the “systemic vascular system can include arterial pressure pulse waveform analysis, Doppler ultrasonography, venography, and arteriography” (McCance & Huether, 2018, ch. 32). Routine imaging is not recommended unless there is a change in the patient’s health status, and less invasive methods are preferred to more invasive ones (Yancy et al., 2017). Lab testing for biomarkers such as BNP are increasingly preferred as a way of detecting HF, in addition to other common signs and symptoms. After an HF diagnosis is confirmed, patients need to understand the future progression of their illness and the interventions that can prevent heart attack, such as taking medication and watching for warning signs. Clinical Guidelines for Patient Education Treating HF requires a medication regimen and may include major lifestyle changes, so patient education is a vital component of any treatment plan (Rice & Betihavas, 2018). The nurse should help to explain the disease process, what the different stages of HF are and what levels of physical activity are possible at each stage. Patients should fully understand their symptoms and be aware of any warning signs that would require emergency assistance. The nurse acts as a patient advocate by empowering the HF patient to manage her illness effectively. The nurse should educate the patient and her family, providing resources for support groups, medical information, and referrals to other specialists and providers. Nurses and pharmacists can assist patients, caregivers, and family members to understand the purpose, dosage, route, contraindications and routine required for each medication that is prescribed. Higher medication compliance is associated with improved outcomes, such as reduced rehospitalization (Greene et al., 2018). Patient education reduces hospitalizations and increases functioning and quality of life among HF patients (Rice & Betihavas, 2018).

HEART FAILURE PATHOPHARMACOLOGY 12 Clinicians, registered dieticians, and physical or occupational therapists can assist with educating patients about proper dietary changes and how to perform moderate physical activities that can be accomplished with minimal risk to their health. Each case of HF is unique, and will require education that targets the patient as a whole person. Some HF patients should increase their levels of physical activity, within reasonable limits, while others should consider limiting intense physical activity in order to avoid a heart attack or worsening of symptoms. An individualized treatment plan is important, because the underlying causes of HF are different for each patient, and include genetic, lifestyle, and environmental components. Education can and should be provided through a variety of methods, including verbal and written instructions, pamphlets, videos, websites, and other resources, as diverse methods of education can result in improved HF patient outcomes (Rice & Betihavas, 2018). Standard Practice of Disease Management Health providers in California follow national guidelines for the management of heart disease and HF (Arnett et al., 2019; Blue Shield of California, 2021; Yancy et al., 2017). Standard practice for the management of HF includes: prevention, screening, diagnosis, pharmacological and surgical interventions, as well as recommended lifestyle changes. Patient education is aimed at ensuring compliance with treatment and modifying or eliminating risky behaviors. Primary Care Providers offer some prevention and screening options, and other medical professionals may also refer the patient for HF assessment. For more complex heart surgeries, patients in Riverside County may have to travel to Orange County or Los Angeles area facilities, which have additional resources and specialists available. Hospitals and outpatient radiology facilities within the larger Inland Empire area can provide imaging services to help with the diagnosis of HF.

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

HEART FAILURE PATHOPHARMACOLOGY 13 As far as pharmacological interventions are concerned, Riverside County is generally equipped to provide cardiac care that mirrors state and national standards. In Riverside County, heart specialists may choose to place their patients on lower cost medications and may be less likely to recommend the latest evidence-based treatments than the clinicians in wealthier areas. 6.5% of adults have heart disease in Riverside county, which puts it in the better half of counties in the state (SHAPE Riverside, 2021). Although some patients may have to travel longer distances or wait for specialist appointments due to the lack of practitioners in Riverside County, specialist clinics such as Inland Heart Doctor and Inland Heart and Vascular Medical Associates provide outpatient services for cardiovascular care. Large hospital groups like Kaiser Permanente and the Riverside University Health System provide emergency and inpatient care for HF patients. The standard of practice for HF in Riverside County is similar to other mid-sized suburban counties in California, which have somewhat limited resources for their healthcare systems. Patients in Riverside County may lack easy access to advanced procedures such as heart transplants or defibrillator implantation due to lack of insurance, insufficient income, or distance from a qualified provider. Managing the Disease Process HF can be managed through a strong network of financial, family, community, and governmental support. There are multiple factors that contribute to a patient being able to manage HF effectively, including personal financial resources, access to care, insurance, public assistance, and charitable contributions. Successful management of HF may be more likely for patients who are younger, of certain ethnic backgrounds, have higher income, have insurance, and have easy access to a variety of care options in their area. The best outcomes will be seen in patients who are female, young, non-African-American, in otherwise fairly good health and

HEART FAILURE PATHOPHARMACOLOGY 14 exhibit few comorbidities like obesity, diabetes, or lung disease. Patients who are able to easily change their lifestyle, for example, by stopping smoking and changing to a low-sodium vegetarian diet, can manage their HF better than those who cannot. Certain groups of patients are more likely to respond well to medications aimed at blocking chemical signals in the body, lowering cholesterol or regulating blood pressure than others. Patients who can access high quality foods, purchase necessary medications, and find safe, affordable ways to exercise like local parks and gyms will have a better time managing their HF. Patients with good insurance and high incomes have many more options when it comes to medications, surgery, and choices of providers. A patient with ample resources can opt to see multiple providers, and may be able to access additional interventions beyond medication, such as surgery. Life expectancy in HF patients depends on the progression of the disease and the steps taken to manage it, but it is generally poor. Managing this illness or preventing it altogether results in increased life expectancy. If it were possible to prevent HF in at-risk patients, it would increase life expectancy by an estimated 1.92 years (Van Nuys et al., 2018). Around 81% of HF patients survive the first year (Durning, 2019). There is a 5-year survival rate of around 48%, meaning about half of new diagnoses will die within five years. The 10-year survival rate for HF is around 26% (Durning, 2019). Outcomes for HF vary depending on the individual patient and progression of the disease process. Early stage HF may respond better to interventions like medications and lifestyle modifications than severe, late stage HF. Patients that are fully engaged in the treatment process and eager to improve their health will have better outcomes than those who fail to make serious efforts to manage their illness. An exhaustive list of risk factors is provided by Crespo‐Leiro et al. (2018, p. 1511) and includes a variety of general patient variables, lab values, and lifestyle

HEART FAILURE PATHOPHARMACOLOGY 15 factors that contribute to high risk in HF patients. The less damaged the cardiovascular system is, as demonstrated by a lack of secondary complications or high functional ability, the better chance the patient has for good outcomes concerning mortality and further progression of HF. Health and Treatment Disparities At the international level, HF is a major health problem, rivaled only by cancer as a cause of death in developed countries (Crespo‐Leiro et al., 2018). As it is a disease that largely affects older people, and those who are overweight or eat a Western diet high in fat, sugar, and sodium, HF is less of an issue for developing nations with younger, thinner populations. On the other hand, advanced treatments and medications are not available in rural areas, poor areas, and countries with small or overburdened healthcare systems (Pesah, Supervia, Turk-Adawi, & Grace, 2017). Diagnosis and treatment of HF has become more effective through the use of technology and highly specialized treatment plans that are tailored to an individual’s genetic background, type and severity of disease. In healthcare settings with less resources, such as those in Africa and the Middle East the latest evidence-based treatments for HF may be unavailable, and patients must rely more basic diagnostic techniques and inexpensive medications (Pesah et al., 2017). Staffing composition and the fundamental methods for diagnosing and treating HF are comparable across the world (Pesah et al., 2017; Wang et al., 2019). However, individual programs may be evaluated according to a number of variables. These include: “capacity and resources, reimbursement sources…patient diagnoses accepted into CR programs…program duration…session frequency…components delivered… alternative model delivery and barriers” to care (Pesah et al., 2017, pp. 267-68). In areas with advanced communications technology, patients and providers can avail themselves of telemedicine services that assist with the transition

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

HEART FAILURE PATHOPHARMACOLOGY 16 from hospital to home care (Pesah et al., 2017). Outpatient and specialized services are more readily available in large, wealthy nations, while smaller, less wealthy nations are likely to deliver care through large hospitals and centralized medical facilities (Pesah et al., 2017). In the US, African-Americans experience worse HF outcomes compared to other ethnic groups. States with high rates of obesity and other associated comorbidities, such as those in the Southern US, exhibit higher rates of HF and cardiovascular illness. California has a lower rate of smoking, higher rate of exercise, and lower rate of obesity than the respective national averages. In California, HF rates are significantly higher among African Americans and Pacific Islanders compared to other ethnic groups (Conroy, 2016; Husaini et al., 2017). African-Americans are more likely to be hospitalized for cardiovascular illnesses compared to any other group in California (Conroy, 2016). Californians boast higher rates of exercise, lower rates of smoking, lower rates of child obesity, and lower rates of heart disease overall compared to the rest of the US. Californians with lower levels of education and income are more likely to report having at least one form of CVD than other groups. Overall, there are major disparities in HF treatment due to geographic location, income, ethnicity, and education level. Though HF treatment is standardized across the US, patients may need to travel to other cities or states in order to receive higher quality specialist care than they would at their local hospital. Factors for Managing HF & Unmanaged Illness Unmanaged HF will result in severe negative impacts on a patient’s health, disability, and death. Due to the high costs and burdens associated with HF, some patients are unable to manage their disease effectively. A combination of factors contributes to the progression of HF in a patient lacking the resources needed to manage this illness. One of the major barriers to treatment is cost, but even with public assistance, patients may still be unable or unwilling to

HEART FAILURE PATHOPHARMACOLOGY 17 access the care they need. Increased support, education, and additional public health resources can improve the management of HF in the local community. Financial Resources Medications for HF can be expensive, and each hospitalization accounts for costs of around $15,000 per patient (Kilgore, Patel, Kielhorn, Maya, & Sharma, 2017). Medication adherence is associated with improved HF management outcomes (Hood et al., 2018). A 10% increase in medication compliance was associated with an 11% decrease in emergency room admissions, 6% decrease in hospital admissions, and decrease in overall mortality of 9% (Hood et al., 2018). Thus, the financial resources needed to make appointments, fill prescriptions and purchase medications can act to reduce the potential costs associated with rehospitalization. Patients who lack financial resources face multiple barriers to receiving effective HF treatment, and may be unable to access the same level of care as someone who is wealthy. Access to Care Access to cardiac care may be limited due to a patient’s location, as rural and poor areas have less services available. Los Angeles and the San Francisco Bay Area have the best medical facilities and practitioners in the state, and patients from more rural areas, such as the Inland Empire, may be underserved when seeking HF care. In California, language barriers and documentation status can impact whether patients can access care, ask effective questions, and understand their treatment plan. The large immigrant population in California faces additional barriers to care due to a variety of factors including poverty, education levels, and beliefs about health (Ortega et al., 2018). Though undocumented immigrant Latinos exhibit some better health outcomes than US-born Latinos, they are much less likely to access healthcare services and more

HEART FAILURE PATHOPHARMACOLOGY 18 likely to report poor health overall (Ortega et al., 2018). Poor access to care is associated with greater morbidity and mortality from HF. Insured/Uninsured 85.4% of adults in Riverside county are insured, lower than both the CA state average of 89.2% and the national average of 88% (SHAPE Riverside, 2021). Older adults, men, mixed race individuals and Latinos are underrepresented in terms of health insurance in Riverside County (SHAPE Riverside, 2021). In Riverside county, 50.6% of residents have private health insurance, lower than state and national averages. Use of public insurance is higher than average, at 31.5% of residents (SHAPE Riverside, 2021). Private insurance is associated with better outcomes for HF disease management. Lack of insurance can lead to unmanaged illness and rapid progression of HF. Nurses can act as patient advocates by making referrals to sign up for private or public insurance as appropriate. In California, emergency Medi-Cal can provide coverage to patients who have low income or do not otherwise qualify for insurance from other providers. Medicare/Medicaid California has a greater rate of Medicaid coverage than the US as a whole (25% to 19%, respectively) (American Heart Association, 2017). Greater insurance coverage, including public health insurance, is associated with better outcomes regarding HF management. Among Medicare beneficiaries, like other HF patients, rehospitalization is a major cost burden. In one study of Medicare coverage for HF, an estimated 40% of HF patients were readmitted within 90 days (Kilgore et al., 2017). Research suggests that Medicare Advantage patients have better outcomes than those with traditional fee-for-service Medicare plans (Daddato, 2020). Overall, private insurance offers better options than Medicare plans for HF patients (Hutcheson et al., 2018).

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

HEART FAILURE PATHOPHARMACOLOGY 19 Unmanaged Disease Factors Patients who lack financial resources, lack access to medical services due to geographic, language, or cultural barriers, lack insurance, or rely on public insurance, may have a more difficult time managing their illness. The current lack of resources for health care services in rural and low-income areas results in fewer physicians and health care professionals to treat patients, increasing the likelihood of patients not necessary HF care. Patients with Unmanaged Disease Aside from external and environmental factors, patients who refuse to modify their behaviors regarding tobacco, alcohol, diet, and exercise, may not be able to manage their HF or prevent the worsening of symptoms. Patients with unmanaged HF may experience a greater increase in the severity of symptoms over time than those who manage it well. As a chronic, progressive illness, HF will lead to disability and death in patients who miss important medical appointments, do not take their medications, or refuse care for any reason. Unmanaged illness will result in functional impairment, an inability to complete physical activities, shortness of breath, pain, edema, and other complications of HF. Psychological health can affect patient outcomes, as depressed patients have worse outcomes and higher rates of hospitalization. Patients who lack proper education and do not understand the importance of managing HF may fail to meet the goals in their treatment plan. Impact on Patients, Families, and Populations HF has a major impact on a patient’s life, as it has a high rate of morbidity, mortality, and a generally poor long-term prognosis. Patients coping with HF will need to make adjustments to their daily routine, change their diet, and manage multiple medications. Impact on patients depends on the progression of the illness. Those with early-stage HF or HF that is limited in

HEART FAILURE PATHOPHARMACOLOGY 20 severity, according to the NYHA scale, will be less impacted than those with serious, end-stage HF. Patients may experience loss, grief, and depression as a result of their diagnosis (Celano, Villegas, Albanese, Gaggin, & Huffman, 2018). Families are gravely impacted by heart disease, as it is a leading cause of death in the United States. The loss of a loved one, a grandmother or grandfather, a parent or child, is an incalculable cost. Family caregivers for those with HF experience emotional, financial, and even physical burdens associated with caring for their loved one (Grant & Graven, 2018). Families need help and support from health care professionals like nurses who can offer education, advice and counsel, and help them to manage the care of a loved one with HF. As HF is often found in older patients who are already impaired, younger relatives may bear the responsibility of taking care of their elders, whether financially or as direct caregivers. When families cannot manage their healthcare costs on their own, some of these expenses may impact the local community, who indirectly pay for care through taxes, Medicare withholding, and charitable donations. The impact of HF on populations is measurable in terms of lost lifespan, lost productivity, and higher medical costs. HF is predicted to double older adults from 4.3% in 2012 to around 8.5% by 2030 (Van Nuys, Xie, Tysinger, Hlatky, & Goldman, 2018). If HF could have been prevented in patients around 50 years old in 2016, it would “generate nearly 2.9 million additional life years, 1.1 million disability-free life years, and 2.1 million quality-adjusted life years worth $210 to $420 billion….[with] gains…greater among black subjects than among white subjects” (Van Nuys et al., 2018). The overall prevalence and incidence of HF are 2% and .2% per year in the West (Savarese & D’Amario, 2018). Communities with high rates of HF are impacted in terms of healthcare costs and losses associated with disability and mortality. In

HEART FAILURE PATHOPHARMACOLOGY 21 California, HF disproportionately impacts men, African-Americans, Pacific Islanders, and Latinos, meaning that these patient populations bear a greater burden from HF than others. Costs A 2012 estimate showed that heart failure cost the United States over $30 billion dollars including healthcare costs, drug costs, and lost productivity (U.S. Department of Health & Human Services, 2020). In California, African-Americans, Pacific Islanders, and males had increased costs associated with hospitalization, due to their higher risk for high blood pressure and diabetes associated with HF (Husaini et al., 2017). One way to manage costs in terms of rehospitalizations is through effective transitional care programs that empower patients to manage their HF safely without repeated trips to the hospital. Hospitalization costs for HF are estimated at around $35,000 per year, with each hospitalization costing around $15,000 (Kilgore et al., 2017). Medication costs are a major factor in the treatment of HF. Multiple medications are required to treat HF. The average monthly cost for HF medications is around $500, with increased costs for Class II and Class III heart failure (Chaemchoi et al., 2020). Medication cost savings can be achieved through medication reconciliation, which reduces duplication of prescriptions, expiration and dispensing of unnecessary medications (Chaemchoi et al., 2020). Newer, brand-name, patented medications are generally more expensive than older or generic alternatives. Best Practices Promotion Best practices for the management of HF involve implementing evidence-based clinical practice guidelines. Although these guidelines are readily available and form a gold standard for HF care, local providers may be ill-equipped to follow them due to a lack of resources or training. Treatment of HF with multiple medications is paramount to promoting positive patient

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

HEART FAILURE PATHOPHARMACOLOGY 22 outcomes. There are several ways to prevent the morbidity and mortality associated with HF in at-risk populations, but the best approach to this problem is to increase the availability of health care services, improve case management, and offer interdisciplinary care options for HF patients. To improve future care and avoid an increase in deaths from HF, nurses should advocate for: targeted interventions for at-risk populations, early screening, patient education aimed at prevention and disease management, subsidized care for the poor and uninsured, and community efforts to reduce contributing factors such as pollution, unhealthy lifestyle choices, obesity, and lack of physical activity (Arnett et al., 2019). Western Governor’s University is partnered with Riverside County through the Riverside University Health System as part of its Community Health Improvement Plan (CHIP) for 2016-2021, which aims to improve heart health within the community through educational outreach. An effective disease management program results in improved patient outcomes over standard care (Kalter-Leibovici et al., 2017). Case management and interdisciplinary teams are associated with improved outcomes for HF management (Takeda, Martin, Taylor & Taylor, 2019). Best Practices Implementation Plan A best practices implementation plan for HF management involves preventing and treating HF while facilitating effective, supportive care post-diagnosis. The organization where I work, Arrowhead Regional Medical Center (ARMC), offers a variety or cardiac care services ranging from diagnosis to rehabilitation. However, advanced services are not currently available through this facility. As part of a partnership with Loma Linda University Medical Center, ARMC does provide high quality HF care to local patients. However, by implementing

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

HEART FAILURE PATHOPHARMACOLOGY 23 additional changes to the current provision of services, ARMC could further improve the management of HF within the local community without transferring patients to another facility. There are a number of deficits in care delivery that could be improved through the implementation of a HF management best practices plan. ARMC received a score of “average” with regards to 30-day survival after hospitalization ("Arrowhead Regional Medical Center Heart Failure Rankings", 2021). This could be improved to a score of high or excellent by improving case management and transition procedures, aligning them with state, national and international standards. ARMC does not perform advanced heart procedures such as left ventricular assist device implantation or heart transplant. Employing specialist staff, building additional facilities, purchasing equipment and securing the licensure required to perform these surgeries represent areas where the ARMC could improve its HF care. In order to qualify as a level I trauma center, the ARMC (currently rated as a level II trauma center) would need to provide open-heart surgery services, which are not available. Implementing the provision of advanced cardiac surgery would significantly improve HF management within the community. Additionally, there is no specialized cardiac intensive care unit to provide specialized HF care. A best practices implementation plan would remedy these deficits by overhauling the process of cardiac care at the ARMC and employing the specialists needed to deliver key services, but this plan would require significant financial investment. The ARMC has been planning to increase the provision of cardiac care services since at least 2007, but progress has been limited by a lack of resources (Griffith-Collison, 2008). Based on the current limitations, a best practices implementation plan aimed at prevention, case management, and interdisciplinary care should be enacted.

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

HEART FAILURE PATHOPHARMACOLOGY 24 Evaluation Method Preventing HF and the progression of HF means promoting access to care. Targeted interventions for at-risk populations to sign them up for cardiovascular screening services can be evaluated based on their response rates. An increase in referrals to specialty HF screening of 50% year-over-year for patients who meet at least one risk factor would signify that additional screening and prevention is being carried out. Effective case management can be evaluated by measuring the rate of rehospitalization among enrolled patients. If the rate of rehospitalization is 10% lower than unenrolled patients, this program should be considered very effective (Hood et al., 2018). However, rehospitalization is not the only important variable for evaluating whether HF is well-managed, and using frequent re-hospitalizations as an indicator of poor care delivery may be misguided (Nayak, Hicks, & Morris, 2020). Finally, the use of interdisciplinary providers can improve outcomes for HF management. Increasing the average number of providers assigned to an HF case by one would indicate that patients have better access to the dieticians, physical therapists, and other assorted specialists that can help them manage their illness. To recap, the ARMC should do a better job of preventing HF incidence and disease progression by referring at-risk patients for screening, as measured by a 50% increase in referrals over one year. Lowering the rate of rehospitalization by up to 10% can be achieved by enrolling patients in an evidence-based case management program for HF. Finally, adding an appropriate member to the interdisciplinary care team can assist patients to better confront the many challenges associated with managing HF. This program should be evaluated for safety and cost-effectiveness at the one-year and two-year marker points. By making incremental changes to the way HF care is delivered, providers can ensure that HF patients experience additional years of life with their families, friends, and loved ones.

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

HEART FAILURE PATHOPHARMACOLOGY 25 References American Heart Association. (2017). California state fact sheet . American Heart Association. Retrieved 17 January 2021, from https://www.heart.org/-/media/files/about-us/policy- research/fact-sheets/quality-systems-of-care/quality-systems-of-care-california.pdf?la=en Arnett, D. K., Blumenthal, R. S., Albert, M. A., Buroker, A. B., Goldberger, Z. D., Hahn, E. J., ... & Ziaeian, B. (2019). 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology , 74 (10), 1376-1414. Arrowhead Regional Medical Center Heart Failure Rankings. (2021). Retrieved 16 January 2021, from https://health.usnews.com/best-hospitals/area/ca/arrowhead-regional-medical- center-6932770/heart-failure Blue Shield of California. (2021). Clinical practice guidelines. Retrieved 7 January 2021, from https://www.blueshieldca.com/bsca/bsc/wcm/connect/provider/provider_content_en/ guidelines_resources/guidelines_procedures/clinical_practice_guidelines Celano, C. M., Villegas, A. C., Albanese, A. M., Gaggin, H. K., & Huffman, J. C. (2018). Depression and anxiety in heart failure: a review. Harvard review of psychiatry , 26 (4), 175. Chaemchoi, T., Weerasaksantia, A., Poohirunkula, T., Chanchenchoa, S., Kunlamasb, Y., & Kositchaiwatb, P. et al. (2020). Economic benefits of medication reconciliation performed by pharmacists in Heart Failure Clinic. Chula Medical Journal , 64 (3), 259-266. doi: 10.14456/clmj.2020.32

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

HEART FAILURE PATHOPHARMACOLOGY 26 Cleveland Clinic. (2021). Heart Failure: Understanding heart failure management and treatment. Retrieved 19 January 2021, from https://my.clevelandclinic.org/health/diseases/17069- heart-failure-understanding-heart-failure/management-and-treatment Crespo‐Leiro, M. G., Metra, M., Lund, L. H., Milicic, D., Costanzo, M. R., Filippatos, G., ... & Ruschitzka, F. (2018). Advanced heart failure: a position statement of the Heart Failure Association of the European Society of Cardiology. European journal of heart failure , 20 (11), 1505-1535. Conroy, S. (2016). Burden of cardiovascular disease in california, 2016 . Los Angeles: UCLA Center of Health Policy Research. Retrieved January 17, 2021 from http://healthpolicy.ucla.edu/publications/search/pages/detail.aspx?PubID=1587 Daddato, A. (2020). The influence of medicare insurance type–traditional fee-for-service v. medicare advantage–on rehospitalizations for patients with heart failure in skilled nursing facilities. (PhD). University of Massachusetts Boston. Retrieved 19 Janurary 2021, from https://scholarworks.umb.edu/cgi/viewcontent.cgi? article=1569&context=doctoral_dissertations Dharmarajan, K., & Rich, M. W. (2017). Epidemiology, pathophysiology, and prognosis of heart failure in older adults. Heart failure clinics , 13 (3), 417-426. Durning, M. (2019). Heart Failure: Prognosis and Life Expectancy. Retrieved 11 January 2021, from https://www.healthgrades.com/right-care/heart-failure/heart-failure-prognosis-and- life-expectancy Gaines, R. (2017). California maps: How many primary care and specialist physicians are in your county?. Retrieved 17 January 2021, from

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

HEART FAILURE PATHOPHARMACOLOGY 27 https://www.chcf.org/publication/california-maps-primary-care-specialist-physicians- county/ Grant, J. S., & Graven, L. J. (2018). Problems experienced by informal caregivers of individuals with heart failure: An integrative review. International journal of nursing studies , 80 , 41- 66. Griffith-Collison, J. (2008). San bernardino county 2007-08 business plan administrative/executive arrowhead regional medical center . San Bernardino: San Bernardino County. Retrieved from http://www.sbcounty.gov/Uploads/CAO/BusinessPlan/2007-2008/2007-08Busines/ HealthCare/ARROWHEAD_REGIONAL_MEDICAL_CENTER.pdf Greene, S. J., Butler, J., Albert, N. M., DeVore, A. D., Sharma, P. P., Duffy, C. I., ... & Fonarow, G. C. (2018). Medical therapy for heart failure with reduced ejection fraction: the CHAMP-HF registry. Journal of the American College of Cardiology , 72 (4), 351-366. Hood, S. R., Giazzon, A. J., Seamon, G., Lane, K. A., Wang, J., Eckert, G. J., ... & Murray, M. D. (2018). Association between medication adherence and the outcomes of heart failure. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy , 38 (5), 539-545. Husaini, B., Taira, D., Norris, K., Moonis, M., & Levine, R. (2017). Depression effects on hospital cost of heart failure patients in California: An analysis by ethnicity & gender. Journal of Cardiac Failure , 23 (8), S77. Hutcheson, S. S., Phillips, V., Patzer, R., Smith, A., Vega, J. D., & Morris, A. A. (2018). Impact of insurance type on eligibility for advanced heart failure therapies and survival. Clinical transplantation , 32 (8), e13328.

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

HEART FAILURE PATHOPHARMACOLOGY 28 IQVIA. (2019). U.S. National Pharmacy Market Summary: Master Insights Report . Retrieved 17 January 2021, from https://www.onekeydata.com/reports/most-powerful-pharmacies Kalter-Leibovici, O., Freimark, D., Freedman, L. S., Kaufman, G., Ziv, A., Murad, H., ... & Silber, H. (2017). Disease management in the treatment of patients with chronic heart failure who have universal access to health care: a randomized controlled trial. BMC medicine , 15 (1), 1-13. Kilgore, M., Patel, H. K., Kielhorn, A., Maya, J. F., & Sharma, P. (2017). Economic burden of hospitalizations of Medicare beneficiaries with heart failure. Risk management and healthcare policy , 10 , 63. McCance, K. L., & Huether, S. E. (2018). Pathophysiology: The biologic basis for disease in adults and children . Elsevier Health Sciences. Nayak, A., Hicks, A. J., & Morris, A. A. (2020). Understanding the Complexity of Heart Failure Risk and Treatment in Black Patients. Circulation: Heart Failure , 13 (8), e007264. NHLBI. (2021). Heart failure. Retrieved 17 January 2021, from https://www.nhlbi.nih.gov/health-topics/heart-failure Ortega, A. N., McKenna, R. M., Pintor, J. K., Langellier, B. A., Roby, D. H., Pourat, N., ... & Wallace, S. P. (2018). Health care access and physical and behavioral health among undocumented Latinos in California. Medical care , 56 (11), 919. Pesah, E., Supervia, M., Turk-Adawi, K., & Grace, S. L. (2017). A review of cardiac rehabilitation delivery around the world. Progress in cardiovascular diseases , 60 (2), 267- 280.

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

HEART FAILURE PATHOPHARMACOLOGY 29 Rice, H., Say, R., & Betihavas, V. (2018). The effect of nurse-led education on hospitalisation, readmission, quality of life and cost in adults with heart failure. A systematic review. Patient education and Counseling , 101 (3), 363-374. Savarese, G., & D'Amario, D. (2018). Sex differences in heart failure. In P. Kerkhof & V. Miller (eds.), Sex-specific analysis of cardiovascular function: Advances in experimental medicine and biology (vol. 1065). Springer. Retrieved 17 January 2021, from https://link.springer.com/chapter/10.1007/978-3-319-77932-4_32 SHAPE Riverside. (2021). SHAPE Riverside. Retrieved 7 January 2021, from http://www.shaperivco.org/ Takeda, A., Martin, N., Taylor, R., & Taylor, S. (2019). Disease management interventions for heart failure. Cochrane Database of Systematic Reviews , (1), CD002752. doi: 10.1002/14651858.cd002752.pub4 U.S. Department of Health & Human Services. (2020). Heart Failure. Retrieved 17 January 2021, from https://www.cdc.gov/heartdisease/heart_failure.htm Van Nuys, K. E., Xie, Z., Tysinger, B., Hlatky, M. A., & Goldman, D. P. (2018). Innovation in heart failure treatment: life expectancy, disability, and health disparities. JACC: Heart Failure , 6 (5), 401-409. Retrieved 17 January 2021, from https://www.sciencedirect.com/science/article/pii/S2213177917308351 Wang, C. C., Wu, C. K., Tsai, M. L., Lee, C. M., Huang, W. C., Chou, H. H., ... & Hwang, J. J. (2019). 2019 focused update of the guidelines of the Taiwan society of cardiology for the diagnosis and treatment of heart failure. Acta Cardiologica Sinica , 35 (3), 244. Yancy, C. W., Jessup, M., Bozkurt, B., Butler, J., Casey, D. E., Colvin, M. M., ... & Westlake, C. (2017). 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

HEART FAILURE PATHOPHARMACOLOGY 30 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 , 70 (6), 776-803. Retrieved 17 January 2021, from https://www.jacc.org/doi/pdf/10.1016/j.jacc.2017.04.025 Ziaeian, B., Fonarow, G. C., & Heidenreich, P. A. (2017). Clinical effectiveness of hydralazine– isosorbide dinitrate in African-American patients with heart failure. JACC: Heart Failure , 5 (9), 632-639. Retrieved 19 January, 2021 from https://www.sciencedirect.com/science/article/pii/S2213177917302780

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

C155_Task1

Related Documents