Clinical Scenario Paper
The
case scenario
in question relates to an 80 year old patient who presents with SOB for 2 days, bibasilar rales and expiratory wheezes. He has 2+ lower extremity non-pitting edema which is unchanged from the previous visit. The rest of the PE is otherwise unremarkable. The patient has a history of CAD, HTN, CKD 3, CHF and COPD. The patient is currently taking lisinopril 10mg QD, metoprolol 12.5mg BID, ASA 81mg daily, Combivent one puff QID, Lasix 20mg QD and KCL 10meq QD.
Heart failure (HF)
is defined by the American College of Cardiology (ACC) and the American Heart Association (AHA) as a complex clinical syndrome resulting from structural or functional impairment of ventricular filling or ejection of blood (Collins-Bride, 2016). The diagnosis of HF is primarily clinical based on classical symptoms including dyspnea, fatigue, fluid retention and exercise intolerance. HF can involve the left ventricle, the right ventricle or both. Left ventricular failure predominantly involve dyspnea and fatigue arising from pulmonary edema whereas right ventricular failure include peripheral edema, ascites, hepatic and splenic congestion secondary to systemic fluid congestion. The most important causes of HF are coronary artery disease (CAD) and hypertension (HTN) (Kennedy-Malone, Fletcher, & Martin-Plank, 2014). Based on the patient’s presenting symptoms and history it appears that he is experiencing an exacerbation of his heart failure. Two evidence based practice articles will be utilized to help inform the diagnosis. One paper focuses on a quantitative approach while the other utilizes a qualitative approach to inform the diagnosis of HF. The conclusion will include the recommendation for the given scenario of the best paper and the rationale for choosing one paper over the other.
Quantitative Research Article
The quantitative paper that was chosen is
the “2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of
the American College of Cardiology Foundation/American Heart Association Task
Force on Practice Guidelines”. There are certain criteria that are used to
critique the quality of quantitative trials such as the purpose of the
research, the depth and quality of the literature review, the overall
objectives of the research, adequate sample size calculations, the methodology
is clearly highlighted (validity and reliability), the analysis of the
quantitative research needs to clearly demonstrate which statistical methods
were utilized for the conclusions and the discussion/conclusion section needs
to be supported by the research data presented (Greenhalgh, 2014). The paper
was a good choice as it summarized the existing literature on the diagnosis and
management of HF based on the level of evidence (quality of the trials used in
the analysis) and the class of recommendation reflecting the size of the
treatment effect. The American College of Cardiology Foundation (ACCF) and the
American Heart Association (AHA) Task Force developed these clinical practice
guidelines to ensure balanced, evidence-based and patient-centric
recommendations for clinical practice. According to Greenhalgh (2014) there are
additional critical review criteria applied to guidelines that needed to be
considered when choosing this paper. 1) Did the preparation of the guideline
involve a significant conflict of interest? This guideline required all
“committee members and peer reviewers of the guideline to disclose all current healthcare-related
relationships, including those existing 12 months before initiation of the
writing effort” (Yancy et al., 2013). “The writing committee chair plus a
minimum of 50% of the writing committee have no relevant relationship with
industry” (Yancy et al., 2013). Therefore, this paper was a good choice. 2) Is
the guideline concerned with a specific topic and appropriate target group? The
paper specifically addresses the comprehensive needs of the HF patient. 3) Did the guideline committee include
experts in the topic area? The guideline included experts (cardiologists,
internists, electrophysiologists, transplant specialists, & RNs) and
independent reviewers with methodological expertise. 4) Were any subjective
judgments by the panel made explicit? Yes, the recommendations were evidenced
based “wherever possible” (Yancy et al., 2013). 5) Were all the data rigorously
scrutinized and evaluated? Yes, an extensive literature review was conducted
with over 40 independent reviewers (Yancy et al., 2013). 6) Was the evidence properly synthesized and
were the conclusions based on the data presented? Yes, the guideline
synthesized the data and conclusions into recommendation based on the level of
evidence and the class of recommendation. 7) Do the guidelines address
variations in medical practice and other controversial areas? Yes, the guidelines
are intended to “assist clinicians in clinical decision making by describing a
range of generally acceptable approaches to the diagnosis, management, and
prevention of specific diseases or conditions. The guidelines attempt to define
practices that meet the needs of most patients in most circumstances. The
ultimate judgment regarding care of a particular patient must be made by the
clinician and patient in light of all the circumstances presented by that
patient. As a result, situations may arise for which deviations from these
guidelines may be appropriate” (Yancy et al., 2013). 8) Are the guidelines written from the
perspective of the practicing doctor, nurse, etc.? Yes, the guidelines
specifically state that they attempt to define practices to meet the needs of
most patients but deviations from the guidelines may be appropriate in certain
clinical situations. This speaks directly to the applicability of the guidelines
to the end practitioner versus the academic or policy maker. This addresses a major critique of guidelines
cited by Greenhalgh in chapter 1 of her book, “why do people sometimes groan
when you mention evidence-based medicine” (Greenhalgh, 2014). 9) Does the
guideline take into account what is acceptable to, affordable by, and
practically possible for patients? Yes, it specifically controlled the level of
industry involvement to reduce the likelihood of bias. 10) Does the guideline include
recommendations for its own dissemination? Yes, “in an effort to maintain relevance at
the point of care for practicing clinicians, the Task Force continues to
oversee an ongoing process improvement initiative where several changes to
these guidelines will become apparent based on the results of ongoing pilot
projects”(Yancy et al., 2013). Based on the patient’s change in clinical status
it is recommended that the patient presenting with acute decompensated HF,
should undergo a chest x-ray to assess heart size and pulmonary congestion and
to detect alternative cardiac, pulmonary, and other diseases that may cause or
contribute to the patient’s shortness of breath. Recommended lab studies
include complete blood count, complete metabolic panel, magnesium level, cardiac enzymes, urinalysis, thyroid-
stimulating hormone, 12- lead electrocardiogram (Level of Evidence: C) and
brain natriuretic peptide (BNP) (Level of Evidence: A). Determining BNP level
is useful for establishing prognosis or disease severity in patients chronic
HF. Also, “a repeat measurement of EF and measurement of the severity of
structural remodeling are useful to provide information in patients with HF who
have had a significant change in clinical status” (Yancy et al., 2013). The
2-dimensional echocardiogram with Doppler flow studies is the most useful
diagnostic test to assess changes to ventricular function. Level C recommendations indicates that the
procedure or treatment is useful based on standard of care and expert
recommendations. Diuretics are
recommended for HF patients with evidence of fluid retention unless
contraindicated to improve symptoms. Given the patient’s symptoms the Lasix
should be increased to 20 mg twice daily (standard recommendation is 20-40 once
or twice daily). Because the patient is
presenting with symptomatic HF he should also be placed on sodium restriction
of <3g daily to reduce congestive symptoms (Level of Evidence: C) (Yancy et
al., 2013).
Qualitative
Research Paper
The qualitative paper that was selected is titled
“Improving care for heart failure patients in primary care, GP’s perceptions: a
qualitative evidence synthesis” by Smeets and colleagues published in the BMJ
in 2016. This qualitative article was interesting because like the previous
quantitative article, reflects a synthesis and meta-analysis of the qualitative
evidence related to the management of HF patients. This paper was unique
because it was one of the first papers to synthesize the qualitative data
related to the management of HF patients from 18 qualitative papers. The paper
concluded that HF was very difficult to diagnose due to lack of specificity of
symptoms, was associated with significant communication issues between the
patient and the multidisciplinary care team, and that the implementation of HF
guidelines was underutilized by primary care physicians
(Smeets et al., 2016). The paper discussed the importance of the
clinical diagnosis, use of chest x-rays, ECGs, laboratory work, and
echocardiograms to manage patients. The current treatment recommendations were
also discussed as was the difficulty of pharmacologically managing the complex
patient with multiple comorbidities such as is the case with our case scenario.
The paper concluded that there was a clear need to improve the diagnosis of HF
with the use of echocardiography and natriuretic peptides that may limit the
number of cases requiring echocardiography. There is a need to translate
existing HF guidelines into more usable local guidelines through the
intervention of local experts. Finally, the paper confirmed the need for
multidisciplinary collaboration. General practitioners admitted that they
feared losing patients to specialists if they referred them (Smeets et al.,
2016).
Similar to the first paper, Greenhalgh
(2014) cites several criteria by which to evaluate or critique the quality of
the qualitative research in question. 1) Did the paper describe an important
clinical problem? Yes, the paper synthesized 18 qualitative barriers assessing
the diagnosis, management and barriers to management of HF patients. 2) Was a
qualitative approach appropriate? Yes, the goal was to synthesize qualitative
papers to gain a deeper understanding of the barriers to care of HF patients.
3) How were the setting and the subjects selected? The authors conducted a
comprehensive literature search and selected only papers that used qualitative
data collection methods. Descriptive and opinion papers were excluded. 4) Was
the researcher’s perspective taken into consideration? Yes, the authors
approached the work specifically from a qualitative research perspective and
sought to synthesize previously conducted original studies. 5) Was the
methodology used described in detail? Yes, the authors describe their
methodology in detail including their critical appraisal methods using the
Critical Appraisal Skills Program (CASP). 6) Did the authors employ a thematic
analysis to their work? Yes, the authors utilized a thematic analysis that
“preserved an explicit and transparent link between conclusions and the text of
the primary studies” (Smeets et al., 2016). 7) Are the results credible and
clinically important? Yes, the authors cited the 18 primary papers used for
their analysis. The results are of high clinical value because it confirmed the
need for better communication of HF guidelines to the community clinician. 8) What
conclusions were drawn and are they justified by the results? Yes, the
conclusions were directly supported by the original research. The
recommendations made are of high clinical importance in my opinion. 9) Are the
findings of the study translatable to other settings? Here, it can be said that
were partially transferrable. The synthesis of qualitative data in the HF
population was a relatively new endeavor and the authors identified a new
method to ensure transparency. The results are primarily based on the UK
population which makes generalizability more challenging to the US population.
However, it can be said that the basic approach to the clinical diagnosis and
management of CHF is similar between Europe and the US with minor regional
variations.
Both a systematic review of quantitative data and a systematic analysis of qualitative data in the diagnosis and management of heart failure were reviewed. Both reviews provide valuable evidence by which to approach the given case scenario. One is very proscriptive in the steps involved in the diagnosis and management and the other highlights the challenges of diagnosis and management encountered by physicians and associated multidisciplinary teams. The qualitative review highlights how challenging the diagnosis of HF is given the presence of non-specific symptoms and the lack of awareness of treatment guidelines among the primary care practitioners. Both reviews were found to be of high quality and high clinical relevance. With respect to the given case scenario the quantitative guidelines publication applies best because it provides the evidentiary base on the differential diagnosis and the step wise management of the patient.
References
-
Collins-Bride, G. (2016).
Clinical Guidelines for Advanced Practice Nursing
(3rd ed.). Burlington,, MA: World Headquarters, Jones & Bartlett Learning. -
Greenhalgh, T. (2014).
How to read a paper: the basics of evidence-based medicine
(5th ed.). Oxford, UK: Wiley Blackwell. -
Kennedy-Malone, L., Fletcher, K. R., & Martin-Plank, L. (2014).
Advanced practice nursing in the care of older adults
. Philadelphia, PA: F.A.Davis Company. -
Smeets, M. (2016). Improving care for heart failure patients in primary care, GPs’ perception: a qualitative evidence synthesis.
Bmj Open, 6
. -
Yancy, C. W. (2013). 2013 ACCF/AHA Guideline for the management of heart failure: A report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines.
Circulation, 128
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