Heart Failure and Blood

¶ … M.K., a 45-year-old female who has a history of Type II diabetes mellitus and primary hypertension. In addition to this, M.K. is overweight and persists with a poor diet. The patient has also been smoking for the past 22 years, and has recently been diagnosed with chronic bronchitis. Current symptoms include chronic cough, which tends to be more severe in the mornings and productive with sputum, light-headedness, distended neck veins, excessive peripheral edema, and increase urination at night. The patient is currently on several medications including Lotensin and Lasix for the hypertension, along with Glucophage for the Type II diabetes mellitus. From an analysis of M.K.'s lab results, this report will offer clinical findings and treatment recommendations, as well as suggestions for what other conditions M.K. may be at risk for given her health history, lifestyle, and lab results as follows:

Vitals

BP

158/98 mm Hg

CBC

Hematocrit

57%

Glycosylated hemoglobin (HbA1c)

Arterial Blood Gas Assessment

PaCO2

52 mm Hg

PaO2

48 mm Hg

Lipid Panel

Cholesterol

242 mg/dL

HDL

32 mg/dL

LDL

173 mg/dL

Triglycerides

1000 mg/dL

Hypertension: Is M.K. experiencing heart failure?

One in every three American adults has high blood pressure, and about half of them have the condition under control (CDC, 2016). According to the CDC (2016), 35% of women in M.K.'s age bracket have high blood pressure. High blood pressure can and does increase the patient's risk for having a heart attack (70% of people having a heart attack have high blood pressure), a stroke (80% of people who have a stroke have high blood pressure), chronic heart failure (70% of people with chronic heart failure had high blood pressure), and kidney disease (CDC, 2016). M.K.'s high blood pressure qualifies as being "controlled" because she is taking medications. The patient's vital signs most recently revealed her blood pressure to be 158/98 mm Hg, which is actually still high and qualifies M.K. for being diagnosed with Stage 1 Hypertension. The patient is currently taking several drugs for managing her hypertension including Lotensin (digitalis) and Lasix. Lotensin is commonly used to treat patients like M.K., and is a targeted medication for hypertension. Lasix is a diuretic that happens to be frequently prescribed in conjunction with Lotensin because the two drugs can have a positive and synergistic effect on treating the hypertension and helping M.K. keep the high blood pressure under control. Unfortunately, M.K.'s hypertension remains uncontrolled in spite of these interventions.

Moreover, M.K.'s uncontrolled pulmonary hypertension places the patient at increased risk of developing the aforementioned health problems including heart failure, which given the cluster of problems she currently faces, may have already happened (Wolf-Maier, et al., 2004). There are, however, several types of heart failure: left-sided, right-sided, and congestive. Left-sided heart failure can be systolic or diastolic. Diastolic left-sided heart failure is also known as diastolic dysfunction. Diastolic dysfunction refers to the inability of the left ventricle muscles to relax and refill with blood; the muscle has stiffened. With systolic left-sided heart failure, the ventricle cannot contract or pump with enough force to circulate the blood. Both of these types of left-sided heart failure can be treated with drugs, but different drugs would be indicated for each condition.

Of course, it would be better to prevent any heart failure that has not already occurred in the patient. In fact, right-sided heart failure, also known as right ventricular heart failure, usually follows left-sided heart failure (American Heart Association, 2015). Congestive heart failure can be even more severe, causing edema and interfering with the kidneys in other ways, too (American Heart Association, 2015). M.K.'s protruding neck veins and her persistent coughing may indicate that she has already suffered from at least one type of heart failure and should get evaluated further. In M.K.'s case, an echocardiogram would clarify which type of heart failure she may have. Right-sided heart failure is more closely connected with M.K.'s comorbidity, including both uncontrolled hypertension and the bronchitis, which is classified under the rubric of chronic obstructive pulmonary disease (COPD). Therefore, it is suspected that M.K. may have right-sided heart failure; an echocardiogram will clarify further. Medications like Lasix can help patients like M.K., but she may also need to add additional pharmacological treatments like beta blockers, angiotensin II receptor blockers, Aldosterone antagonists, or inotropes if the condition worsens. Given the patient has already been prescribed Lanoxin, it is also likely that the medical team has recognized symptoms of systolic heart failure already.

As M.K. is hypertensive, and because her medications are failing to fully control the hypertension due to her smoking and poor diet, it is easy to see how she is at an especially high risk for heart failure. M.K. is one of the two-thirds of Americans who are at increased risk for cardiovascular events like heart failure because of inadequate blood pressure control: "only 34% of the 50 million American adults with hypertension have their blood pressure controlled to a level of

The patient was tested for HBA1C, a glycated hemoglobin measure. A controlled study of over 1000 individuals showed that HBA1C is a "reliable predictor of coronary artery disease and the magnitude of perfusion defects and LVD and the incidence of NFMIs are higher at an HBA1C level greater than 7.3%," (Fatima, 2013, p. 489). M.K.'s test results show that indeed, the patient has an HBA1C level of exactly 7.3%. Her risk for cardio-pulmonary failure is quite extraordinary. Furthermore, M.K's lipid panel shows that her total cholesterol is at 242 mg/dL, which is high, putting the patient at further risk of heart attack and/or heart failure as well as stroke. Her HDL is at 32 mg/dL, which is too low, and her LDL is at 173 mg/dL, which is high. M.K.'s triglycerides are high at 1000 mg/dL. Therefore, the patient can be classified as having hypertriglyceridemia. Hypertriglyceridemia is "common in the United States" because so many Americans lead lifestyles like that of M.K (Sweeney, 2016). Moreover, having diabetes mellitus, obesity, and sedentary habits places M.K. at further risk of developing the problems related to heart failure and probably other conditions due to her unwillingness to change (Sweeney, 2016). M.K.'s lipid counts are testimony to her poor diet, placing the patient at increased risk of a number of cardiovascular-related illnesses starting with atherosclerosis at the very least, which further increases the patient's likelihood of heart failure. The patient could be placed on another medication to control her cholesterol levels; Lipitor is commonly prescribed for this condition.

Smoker's Cough

M.K.'s chronic bronchitis, a feature of COPD, also shows how the patient is unwilling to change her smoking habits. According to Pauwels & Rabe (2004), COPD is the fifth leading cause of death worldwide, "a major cause of chronic morbidity and mortality and represents a substantial economic and social burden throughout the world," (p. 613). M.K.'s smoking can therefore be seen as a socially irresponsible and unethical behavior as well as a morbid one. Healthcare workers sometimes underestimate the "substantial morbidity associated with COPD," causing patients to also underestimate their likelihood of death (Pauwels & Rabe, 2004, p. 613). Tobacco smoking is "by far the major risk for COPD," (Rauwels & Rabe, 2004, p. 613). Therefore, stopping smoking will reduce the patient's overall risk for having the disease progress. At this stage, the patient has already been diagnosed with chronic bronchitis. Her symptoms continue to present themselves accordingly: the sputum production and the coughing. Chronic bronchitis and other elements of COPD are progressive and will continue to worsen especially if exposure to the pathogen, like cigarettes, persists. The only way that M.K. can potentially stop or even reverse the chronic bronchitis is to stop smoking.

Unfortunately, though, M.K. has been smoking for 22 years, and "the disease may still progress due to the decline in lung function that normally occurs with aging, and some persistence of the inflammatory response," (Rauwels & Rabe, 2004, p. 613). COPD is often comorbid with other conditions that M.K. has too, including pulmonary hypertension. There are many other clinical outcomes of chronic bronchitis in addition to the lung-related issues: "Many patients with COPD may have decreased fat-free mass, impaired systemic muscle function, osteoporosis, anemia, depression, pulmonary hypertension, cor pulmonale, and even left-sided heart failure," (Mosenifar, 2016). The patient's heart failure may therefore be left-sided already, which may be progressing into right-sided heart failure or congestive heart failure. As Mosenifar (2016) also points out, COPD has been associated with chronic depression, which may account for the patient's lack of interest in changing her lifestyle and her death-seeking, health-avoiding behaviors. In one a population-based, cross-sectional study of 1,927 participants, researchers discovered a link between COPD and increased risk for risk for mild cognitive impairment (MCI); another study showed similarly that prevalence of MCI was significantly higher in patients with COPD than in those without COPD (Mosenifar, 2016). Patients have almost twice the odds of developing cognitive impairments if they have COPD; the longer the patients have the disease, the more likely they are to develop MCI (Mosenifar, 2016). Moreover, progressive cardiac failure and respiratory failure often coincide with one another, showing that there is a strong connection between the patient's heart failure and the COPD itself; both may be linked to the smoking even more so than to diet, because it is clear that patients with chronic bronchitis are often overweight (Fayyaz, 2016).

The patient was tested further and given arterial blood gas assessment, which yielded a partial pressure of oxygen (PaO2) level of 48 mm Hg, and a Partial pressure of carbon dioxide (PaCO2) of 52 mm Hg. These readings are related to both the pulmonary hypertension and also the chronic bronchitis. Her hemocrit levels are at 57%, which is high. Unfortunately, her Glycosylated hemoglobin (HbA1c) levels are also high, at 7.3%, showing that whatever the patient has been doing to control her diabetes, including taking Glucophage is not working any longer. The patient's problems are all correlated. Symptoms like the excessive peripheral edema, and increase urination at night (nocturia) are also related to the cluster of symptoms linked to diabetes. However, the nocturia might also be related to the patient's taking a diuretic. The edema is related not just to the diabetes but also the hypertension, which are strongly correlated (Cheung & Li, 2012).

The strongest and most important recommendation is to get the patient to stop smoking immediately. If the patient refuses to stop smoking, any additional interventions should be seen as a hostile burden on the healthcare system. The patient is free to explore a range of interventions that make help with her ability to quit smoking, including the use of nicotine patches and similar alternatives. Counseling might also help to identify the root causes of the patient's addiction. If the patient refuses to change, and if the healthcare team is still willing to help the patient, then cough suppressants might provide some short-term relief on occasion; some short-acting beta-agonists ipratropium bromide and theophylline "can be used to control symptoms such as bronchospasm, dyspnea, and chronic cough," (Fayyaz, 2016). Some nonsteroidal anti-inflammatory drugs may also be useful in some cases. Some antibacterials like amoxicillin and doxycycline may be helpful in some situations. However, antibiotics have not proven effective in treating chronic bronchitis and should be avoided (Fayyaz, 2016). Ideally, the patient can quit smoking with a long-term goal of symptom reduction.

The patient has also a history of diabetes, and research is revealing a possible direct metabolic pathway connection between these two concurrent conditions Diabetes and hypertension "frequently occur together," and there is "substantial overlap between diabetes and hypertension in etiology and disease mechanisms," (Cheung & Li, 2012, p. 160). Moreover, "hypertension and diabetes are two of the leading risk factors for atherosclerosis and its complications, including heart attacks and strokes, (Cheung & Li, 2012, p. 160). Given the patient's lipid readings, she may already have atherosclerosis. Chronic stress may also be a problem for M.K., and the patient should be given a full psychiatric evaluation to see if her coping mechanisms are faulty and leading to the problems she has with unwillingness to change her lifestyle: "epidemiologic investigations have demonstrated that mental stress is associated with hypertension, cardiovascular disease, obesity, and the metabolic syndrome," (Cheung & Li, 2012, p. 160). Stress may be causing the patient to continue resorting to old and deleterious habits like smoking and bad eating, which further exacerbates the disease. Likewise, the patient's poor health may be contributing to her overall sense of stress. Cheung & Li (2012) state outright, "people should reduce stress to escape from the vicious cycle of mental stress, obesity, diabetes, and hypertension," (p. 160). Based on the evidence, M.K. is advised to seek some form of therapeutic intervention that includes stress reduction techniques and targets mental health as well as physical health.