Case Author
Joshua W. Skaggs, PharmD
Jessica Wooster Thomas, PharmD, BCACP
Camile Thornton, PharmD

Expert Guests
Kristin Watson, PharmD, BCCP
Robert DiDomenico, PharmD

Joshua Skaggs PGY2 Am Care Resident Memphis VA Medical Center Memphis, TN

Jessica Wooster Clinical Pharmacy Practitioner Memphis VA Medical Center Memphis, TN

Kristin Watson Clinical Pharmacy Practitioner Baltimore VA Medical Center Baltimore, MD

Robert DiDomenico Associate Professor University of Illinois at Chicago School of Pharmacy

The Case!

Setting

VA Medical Center – Heart Failure Clinic

Patient Demographics

The patient is a 79 year old white male

_{^✦Unless otherwise noted, the patient’s sex assigned at birth and current gender identity are congruent.}

Reason for Visit

The patient presents to the heart failure clinic for routine follow-up and optimization of his medications.

History of Present Illness and Presenting Symptoms

The patient is doing well today with no new complaints. He has baseline dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, and chest pain, which comes and goes.

The patient is a 79-year-old male with end-stage renal disease receiving dialysis Monday/Wednesday/Friday. The patient reports that his blood pressure has been running low on his dialysis days, usually averaging 90/50 mmHg, and states that his dialysis has been halted several times as a result.

Cardiology was originally consulted due to elevated troponin, noted this patient is post percutaneous coronary intervention with unchanged 60-70% mid-LAD lesion and heavily calcified coronary arteries.

Past Medical History

• Cardiomyopathy
• Coronary Artery Disease
• Heart failure with reduced ejection fraction
• Chronic combined systolic and diastolic heart failure
• End-stage renal failure on dialysis
• Atrial fibrillation
• Chronic hypoxemic respiratory failure
• History of deep vein thrombosis
• Aneurysm of iliac artery
• Aneurysm of infrarenal abdominal aorta
• Secondary pulmonary hypertension
• Type 2 diabetes mellitus without complications
• Anemia
• Dyslipidemia

Social History and Insurance

Diet: endorses following a low sodium diet. Does report drinking 1-2 cups of coffee daily
Tobacco: Reports smoking 6-8 cigarettes daily
Alcohol: Reports drinking one beer and one shot weekly
Illicit substances: Denies
Insurance: Tricare, Medicare A, B, and D

Family history

• Not recorded during this visit

Current Medications

• Acetaminophen 500 mg tab; Take one tablet by mouth Q8h PRN for pain
• Albuterol 0.083% inhalation solution; Inhale 1 unit dose via nebulizer Q6h PRN shortness of breath
• Albuterol 90 mcg HFA inhaler; Inhale 2 puffs Q6h PRN shortness of breath
• Apixaban 5 mg tab; Take 1 tablet by mouth BID for stroke prevention
• Atorvastatin 80 mg tab; Take 1 tablet by mouth daily for cholesterol
• Cefuroxime 500 mg tab; Take 1 tablet by mouth daily for UTI prevention
• Cetirizine 10 mg tab; Take ½ tablet by mouth daily PRN allergies
• Cinacalcet 30 mg tab; Take 1 tablet by mouth daily
• Docusate NA 100 mg cap; Take 1 capsule by mouth QHS to soften stool
• Fluticasone prop 50 mcg nasal spray; Instill 1 spray in each nostril once daily for allergies
• Folic acid 1 mg tab; Take 1 tablet by mouth daily to supplement folic acid
• Latanoprost 0.005% opth soln; Instill 1 drop in each eye every evening to lower eye pressure
• Lidocaine 5% patch; Apply 1 patch affected area as directed for pain
• Melatonin 3 mg tab; Take 2 tabs by mouth QHS for sleep
• Metoprolol succinate 100 mg SA tab; Take ½ tablet by mouth daily for heart failure
• Mirtazapine 30 mg tab; take 1 tablet by mouth at bedtime for insomnia
• Olodaterol/tiotropium 2.5mcg/ act; Inhale 2 puffs by mouth daily for COPD
• Pantoprazole 40 mg DR tab; Take one tablet by mouth daily before breakfast for GERD
• Sacubitril 24mg/Valsartan 26mg tab; Take 1 tablet by mouth BID for heart failure
• Sevelamer carbonate 800 mg tab; Take 1 tablet by mouth TID AC for phosphorus

Physical Exam Findings / Vital Signs (TODAY)

Review of systems

• Dyspnea at rest: + (stable)
• Dyspnea on Exertion: +
• Orthopnea: +/-  occasional
• PND: –
• Fatigue: + (stable)
• Edema: –
• Angina: –
• Palpitations: –
• Dizziness/syncope: –
• Nocturia: – does not produce urine

Weight	73 kg (160 lb)
Height	170.2 cm (67″)
BMI	25.1 kg/m2
Blood Pressure	114/82 mmHg
Temperature	99.1 °F
Pulse Rate	113 bpm
Pain Rating	0/10

Pertinent Laboratory Findings

Component	Reference Range & Units	Today
Glucose	67 – 99 mg/dL	130 (High)
Sodium	135 -145 mEq/L	130
Potassium	3.6 – 5.1 mEq/L	4.6
Chloride	98 – 106 mEq/L	92
Magnesium	1.5 – 2.4 g/dL	2.0
AST	10 – 42 IU/L	17
ALT	6 – 45 IU/L	14
Creatinine	0.44 – 1.03 mg/dL	7.1
eGFR	Abnormal <60 ml/min/1.73M	<15
BNP	< 100 pg/mL	2893
Total Cholesterol	150 – 200 mg/dL	124
HDL-C	> 40 mg/dL	59
LDL-C	< 130 mg/dL	56
Triglycerides	40 – 150 mg/dL	45
Hgb	13.0 – 18.0 g/dL	9.0
Hct	37.9 – 49.0%	27.4

Echo results: LVEF 25-30%

EKG Results:

VENT RATE: 99         PR INTERVAL:           QRS DURATION: 112
QT: 326               QTC: 418
P AXIS:               R AXIS:                T AXIS: 124

SPIROMETRY:

FVC       2.34 L  (69% predicted)
FEV1      1.49 L  (56% predicted)
FEV1/FVC  64%
POST BRONCHODILATORS
FVC       2.53 L  (75% predicted)
FEV1      1.69 L  (64% predicted)

Mild obstructive ventilatory defect which is improved with bronchodilators.

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FINAL NOTE:  This program will be available for recertification credit through the American Pharmacists Association (APhA) Board Prep and Recertification Program.  To learn more, visit the APhA Board Prep and Recertification website and sign up for the Evidence-Based Practice Series.

References and Resources