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Justification and epidemiology

The chosen disease in this scenario is "Heart Failure with Preserved Ejection Fraction (HFpEF)." The rationale for selecting HFpEF is its increasing prevalence and significant impact on healthcare systems, especially among older individuals with comorbidities like hypertension and type 2 diabetes mellitus.  In the community, approximately 50% of patients with HF have HFpEF (Dunlay et al., 2017). In the Australian context, HFpEF is a growing concern due to an aging population. Its prevalence is rising, partly because of the increasing incidence of risk factors like hypertension and diabetes. Elderly individuals, particularly women, are more susceptible to HFpEF. In 2017–18, more than 500,000 Australian women had one or more heart, stroke, and vascular disorders, and more than 22,200 of them passed away in 2016 due to cardiovascular disease (Australian Institute of Health and Welfare, 2019). This condition diminishes patients' quality of life and leads to frequent hospitalisations and cardiovascular events, contributing to healthcare resource utilisation and costs (Nagueh, 2021).

Script for Pathophysiology and Pharmacology

Pathophysiology

Normal Physiology:

Normal heart function is a highly coordinated and intricate process essential for maintaining the body's oxygen and nutrient supply. The heart has four chambers: two atria (upper chambers) and two ventricles (lower chambers). The left ventricle (LV) and the right ventricle (RV) are primarily responsible for pumping blood. During each cardiac cycle, the heart undergoes systole and diastole (Arvidsson & Kovács, 2022).

During systole, the LV contracts forcefully, generating the pressure needed to eject oxygen-rich blood into the aorta, which delivers it to the rest of the body. Simultaneously, the RV contracts, pumping oxygen-depleted blood into the pulmonary artery, leading to lung oxygenation. Following systole, diastole begins. This phase involves the relaxation and filling of the heart chambers. During diastole, the ventricles expand, allowing blood from the atria to flow into the ventricles, preparing the heart for the next contraction (Smith et al., 2022).

Pathophysiology during HFpEF  :

HFpEF involves intricate cellular-level changes in the heart that collectively impair diastolic function:

Myocardial Hypertrophy: Chronic pressure overload from conditions like hypertension leads to LV hypertrophy. Initially, this adaptation helps maintain cardiac output, but it increases myocardial stiffness and reduces compliance, making it challenging for the heart to relax and fill adequately during diastole.

Fibrosis: Excessive collagen deposition in the myocardium results in fibrosis. Fibrotic tissue is less compliant, impairing diastolic relaxation and cardiac filling (Saheera & Krishnamurthy, 2020).

Endothelial Dysfunction: Inflammatory processes associated with diabetes and obesity can lead to endothelial dysfunction. This affects the availability of nitric oxide (NO), a molecule that promotes vasodilation and overall heart health. Reduced NO availability can impair coronary perfusion and contribute to HFpEF (Zuchi et al., 2020).

Impaired Calcium Handling: Dysregulated intracellular calcium handling in cardiomyocytes affects contractility and relaxation. Abnormal calcium handling can disrupt the delicate balance between systole and diastole, exacerbating diastolic dysfunction.

Increased Stiffness: Changes in the extracellular matrix and alterations in cardiomyocyte titin isoforms contribute to increased myocardial stiffness. This increased stiffness makes it more challenging for the heart to relax and fill adequately during diastole.

Left Atrial Enlargement: Due to increased LV filling pressures during diastole, the left atrium may enlarge as it attempts to accommodate the excessive blood volume. This can further contribute to diastolic dysfunction and worsen symptoms (Darwin et al., 2018).

Risk Factors and Causes:

Heart Failure with Preserved Ejection Fraction (HFpEF) is a complex condition often associated with various risk factors and underlying causes:

Age: HFpEF is more prevalent among the elderly population. As people age, structural changes in the heart and blood vessels can lead to impaired diastolic function, contributing to HFpEF.

Hypertension: Chronic high blood pressure places increased stress on the heart. Over time, this can lead to LV hypertrophy (enlargement of the heart muscle) and myocardial stiffness, impairing diastolic relaxation (Nair, 2020).

Diabetes Mellitus: Diabetes is associated with systemic inflammation, oxidative stress, and endothelial dysfunction. These factors can negatively impact the structure and function of the heart, increasing the risk of HFpEF. Elevated blood sugar levels can also cause microvascular damage within the heart muscle (Mengozzi et al., 2021).

Obesity: Excess body fat, particularly visceral fat, is linked to chronic inflammation and altered adipokine secretion. These factors can contribute to systemic inflammation and oxidative stress, further impairing heart function and increasing the likelihood of HFpEF (Palma et al., 2022).

Coronary Artery Disease (CAD): A history of myocardial infarctions or ischemic heart disease can damage the heart muscle. CAD-related issues can increase LV pressures during diastole, contributing to HFpEF (Piché et al., 2018).

Valvular Heart Disease: Conditions such as aortic stenosis or mitral regurgitation can cause abnormal blood flow patterns and increased LV filling pressures, possibly contributing to HFpEF (Smiseth et al., 2022).

Atrial Fibrillation: Irregular heart rhythms, as seen in atrial fibrillation, can disrupt diastolic filling, impairing cardiac output and exacerbating HFpEF (Reddy et al., 2020).

Pharmacology

Angiotensin Receptor Neprilysin Inhibitors (ARNIs), of which Sacubitril/Valsartan (Entresto) is a specific example, are a class of medications that are frequently used to treat Heart Failure with Preserved Ejection Fraction (HFpEF) (Riaz et al., 2023). To address different facets of the pathophysiology of HFpEF, sacubitril/valsartan combines the effects of an Angiotensin Receptor Blocker (ARB) and a Neprilysin Inhibitor. Angiotensin II effects are lessened by the ARB component Valsartan, which also improves diastolic function and lowers blood pressure and cardiac afterload.

The nephrolysin inhibitor Sacubitril, on the other hand, raises natriuretic peptide levels, boosting vasodilation, lowering fluid retention, and improving heart function (Aroor et al., 2021). Given her history of hypertension and diabetes, the 58-year-old female patient with HFpEF may require frequent monitoring of blood pressure, renal function, and potassium levels while using this drug. Additionally, it's important to carefully consider any potential drug interactions and educate the patient on symptom management and medication compliance. For the best care of HFpEF, routine follow-up visits are essential to monitor treatment effectiveness and safety (Jaarsma et al., 2021).

In conclusion, HFpEF is a multifaceted condition with various risk factors and intricate cellular-level changes in the heart. Understanding these pathophysiological processes is essential for developing effective treatments and interventions for HFpEF patients. It underscores the need for a comprehensive approach that addresses the underlying risk factors and the cellular mechanisms contributing to this condition to improve patient outcomes and quality of life.

Impact of chronic disease on patient

Heart Failure with Preserved Ejection Fraction (HFpEF) profoundly and multifacetedly impacts the patient's life. This chronic condition significantly diminishes the patient's quality of life through various physical and emotional channels (Tourki & Halade, 2021). HFpEF presents with a range of distressing symptoms that, when combined, drastically affect daily living. Dyspnea, a hallmark symptom of HFpEF, can strike during the slightest exertion or even at rest. The sensation of breathlessness can be overwhelming and deeply unsettling, causing patients to curtail their physical activities. Tasks once mundane, such as climbing stairs or walking short distances, become arduous challenges (Vaishnav & Sharma, 2022). This loss of physical capacity can lead to a loss of independence, negatively impacting the patient's self-esteem and overall well-being (Toledano-González et al., 2019).

Fatigue is another pervasive symptom that plagues HFpEF patients. The relentless fatigue robs individuals of their vitality and enthusiasm, isolating them from social and recreational activities that once brought joy and fulfilment. Exercise intolerance further compounds the issue (Lam & Chandramouli, 2018). HFpEF patients find themselves unable to engage in physical activities they once enjoyed. The inability to participate in these activities can lead to frustration, social isolation, and a sense of loss, further deteriorating the patient's quality of life (Jaarsma et al., 2021).

Fluid retention in HFpEF leads to edema, which increases discomfort and inconvenience. Physical discomfort can result from swollen ankles, legs, and occasionally even the abdomen. These conditions also add to a sense of heaviness and sluggishness. Potential side effects may cause additional distress on top of the difficulties associated with managing a complex pharmaceutical regimen (Iacovoni et al., 2022). In addition to its physical effects, HFpEF can have a significant emotional impact. Depression and anxiety might result from the condition's chronic nature and ongoing symptoms. Isolation and resentment might result from losing one's independence and being unable to enjoy life's pleasures (Jiang et al., 2021).

Long-term management and health promotion strategies

In addition to addressing the complex effects of the condition, long-term care solutions for patients with Heart Failure with Preserved Ejection Fraction (HFpEF) seek to improve health and independence. To treat symptoms and prevent complications, medication optimisation and adherence are essential, and patient education comes first. Weight control, frequent exercise catered to the patient's ability, and dietary adjustments all contribute to improved cardiovascular health and general well-being (Pedretti et al., 2023).

The emotional toll of HFpEF must be addressed, and feelings of loneliness and sadness must be fought with the help of psychological assistance and social interaction. Effective care is aided by consistent medical monitoring, thorough illness education, and fall prevention strategies (Ladwig et al., 2022). A comprehensive strategy for long-term HFpEF management also has to include access to community resources, medication administration and monitoring, and advance care planning. These methods increase patients' independence and general quality of life by enabling them to live fulfilling lives while treating the complications of HFpEF (Hossain et al., 2022).

Justification of nursing care

A significant concern is the abrupt exacerbation of HFpEF symptoms. The necessity of prompt intervention in these situations is supported by evidence. The importance of optimising drug use in the management of HF is emphasised in the American College of Cardiology (ACC) and American Heart Association (AHA) guidelines. A tried-and-true method to relieve symptoms and lessen congestion is medication optimisation, which includes modifying diuretics and adding vasodilators (Heidenreich et al., 2022).

A low-sodium diet, in particular, is essential for managing HFpEF because it reduces fluid retention and congestion. Dyspnea, a typical symptom of HF exacerbations, is decreased by oxygen therapy, and oxygenation is improved (Crane, 2021). In addition, intravenous (IV) diuretics might be required in extreme circumstances to hasten fluid drainage and alleviate symptoms (Narasimhan et al., 2021). Early detection and intervention are made possible by empowering the patient with daily weight monitoring and education on symptom recognition in accordance with evidence-based HF management guidelines (de Boer et al., 2022).

Uncontrolled hypertension in a patient with a history of hypertension and HFpEF is a risk factor for further cardiovascular complications (Slivnick & Lampert, 2019). Evidence from the 2022 ACC/AHA Hypertension Guidelines underscores the importance of lifestyle modifications and medication adjustments for effective hypertension management (Heidenreich et al., 2022). Medication adjustment aligns with evidence-based practices for hypertensive patients, as highlighted in a study by Al Makki et al. (2022). Lifestyle changes, including dietary sodium reduction and stress management, are pivotal for enhancing blood pressure control and overall cardiovascular health (Shamsi et al., 2021).

 Daily blood pressure monitoring is supported by research, empowering patients to actively engage in their care, boost medication adherence, and improve hypertension management, as indicated by McBride et al. (2020). Patient education is backed by substantial evidence, promoting informed decision-making and adherence to lifestyle changes and medications. Regular follow-up appointments align with hypertension management guidelines, ensuring continual assessment, treatment optimisation, and long-term reduction of cardiovascular risks (World Health Organisation, 2021).

References

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Aroor, A. R., Mummidi, S., Lopez-Alvarenga, J. C., Das, N., Habibi, J., Jia, G., & DeMarco, V. G. (2021). Sacubitril/valsartan inhibits obesity-associated diastolic dysfunction through suppression of ventricular-vascular stiffness. Cardiovascular Diabetology, 20(1), 1-18. https://doi.org/10.1186/s12933-021-01270-1

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