chronic care integration for endemic ncds.pdf - ncd alliance
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the pih guide to
Chronic Care Integration for Endemic Non-Communicable Diseases
rwanda edition
the pih guide toChronic Care Integration for Endem
ic Non-Com
municable D
iseasesrw
anda edition
Partners In Health
Harvard Medical School Department of Global Health and Social Medicine Program in Global Non-Communicable Disease and Social Change
Brigham and Women’s Hospital Division of Global Health Equity
Partners In Health is a 501(c)3 nonprofit corporation based in Boston, Massachusetts. Established in 1987, PIH is committed to making a preferential option for the poor by working with sister organizations to improve the health and well-being of people living in poor communities. To this end, PIH provides technical and financial assistance, medical supplies, and administrative support to partner projects in Haiti, PerZu, Russia, Rwanda, Lesotho, Malawi, Mexico, Guatemala, Burundi, Kazakhstan, the Dominican Republic, and the United States. The goal of these partnerships is neither charity nor development but rather “pragmatic solidarity”— a commitment to struggle alongside the destitute sick and against the economic and political structures that cause and perpetuate poverty and ill health. Partners In Health is a!liated with the Division of Social Medicine at Harvard Medical School and the Division of Global Health Equity at the Brigham and Women’s Hospital.
More information on Partners In Health can be found at our web site: www.pih.org
the pih guide to
Chronic Care Integration for Endemic Non-Communicable Diseases
rwanda edition
Partners In Health
Harvard Medical School Department of Global Health and Social Medicine Program in Global Non-Communicable Disease and Social Change
Brigham and Women’s Hospital Division of Global Health Equity
s66666
s66666
About the Cover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contributors and acknowledgements
Editor-in-ChiefT494'!"P8:$9C'R(C'G8(
Principal AuthorsL.)+4'M)554%C'R(C'RG,'T494'M<$9C'R('T494'!"P8:$9C'R(C'G8(
Managing EditorL.)+4'M)554%C'R(C'RG,
Special ContributorsU%)+'M%$P$"4%C'R(C'G8('VS8$-#4%'JW'G$..)$#)@4'S$%4XI&*4-8'R"+":3)#*)C'R('$95';$.-8'R&%#&9'!&.:$9'???C'R('VS8$-#4%'0W'S$%5)$+'Y"%A4%7XL95%4$'!%$"9C'R('VS8$-#4%'ZW';49$.'[$)."%4XS8$%.&##4'!$@":$C'R('$95'L9$95'\$)57$C'R('VS8$-#4%']W'()$34#4*X
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Contributors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`$#$.)4'
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ii chronic care integration for endemic non-communicable diseases
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iv chronic care integration for endemic non-communicable diseases
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table of contents
foreword xxiii;464%49+4*' EE)))
abbreviations xxv
chapter 1Integration of Chronic CareServices in Rwanda 1/>/' H84'F&9A'H$).'&6'U954:)+'`&92S&::"9)+$3.4'()*4$*4*')9';<$95$' /
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chapter 2Palliative Care and Chronic Care 17J>/' ,)*#&%7'$95'G8).&*&-87'&6'G$..)$#)@4'S$%4'U66&%#*')9''
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vi chronic care integration for endemic non-communicable diseases
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chapter 3Role of Community Health Workers, Family Planning, Mental Health, and Social Services in the Treatment of Chronic Disease 33B>/' S&::"9)#7',4$.#8'_&%P4%*' BB
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chapter 4Heart Failure 39
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table of contents vii
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viii chronic care integration for endemic non-communicable diseases
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chapter 5Cardiac Surgery Screening, Referral, Anticoagulation, and Postoperative Management 1070>/' ,)*#&%7'&6'S$%5)$+'Y"%A4%7')9';<$95$' /1]
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table of contents ix
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chapter 6Chronic Kidney Disease 135Z>/' U#)&.&A7'&6'S8%&9)+'M)5947'()*4$*4')9';"%$.';<$95$' /B0
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chapter 7Diabetes 153
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chapter 8Hypertension 187g>/' S.)9)+'$95'S&::"9)#72!$*45',7-4%#49*)&9'Y+%449)9A' /gd
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table of contents xi
g>]' [&..&<2a-'H%4$#:49#'6&%',7-4%#49*)&9' J10g>]>/' R$9$A4:49#'&6'_4..2S&9#%&..45',7-4%#49*)&9'&9''
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g>g' ,7-4%#49*)&9')9'G%4A9$9+7' J1Zg>g>/' ,7-4%#49*)&9')9'U$%.7'G%4A9$9+7'VS8%&9)+',7-4%#49*)&9X' J/1g>g>J' ,7-4%#49*)&9')9'F$#4%'G%4A9$+7'VT4*#$#)&9$.''
,7-4%#49*)&9'$95'G%44+.$:-*)$X' J//g>g>B' ;4+&A9)#)&9'$95'R$9$A4:49#'&6'U:4%A49#'S&95)#)&9*' J//g>g>K' Y+%449)9A'6&%'G%44+.$:-*)$' J//g>g>0' H%4$#:49#'&6'G%44+.$:-*)$'L++&%5)9A'#&''
g>g>0>/' R).5'#&'R&54%$#4'G%44+.$:-*)$'' J/Jg>g>0>J' R).5'#&'R&54%$#4'T4*#$#)&9$.',7-4%#49*)&9' J/J
chapter 9Rheumatic Heart Disease Prevention 217d>/' G%4@49#)&9'&6'L+"#4';84":$#)+'[4@4%W'R$9$A4:49#''
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chapter 10Chronic Respiratory Disease 235/1>/' H84'!"%549'&6'S8%&9)+';4*-)%$#&%7'()*4$*4')9';"%$.';<$95$' JB0
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xii chronic care integration for endemic non-communicable diseases
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chapter 11Epilepsy Forthcoming
epilogue 255
appendix aEssential Equipment and Medicines 257L>/' U**49#)$.'UO")-:49#' J0]
L>J' U**49#)$.'R45)+)94*' J0]
appendix bCost Models 261!>/' Y"::$%7'&6'b-4%$#)&9$.'S&*#'R&54.*' JZ/!>J' S$%5)&:7&-$#87' JZJ
!>J>/' S&*#'?9-"#*' JZJ!>J>J' L99"$.';4A):49'S&*#*'G4%'G$#)49#' JZJ!>J>B' G&-".$#)&9'LA4'()*#%)3"#)&9'$95'S$*42[)95)9A''
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!>0' ()$34#4*' JZZ!>0>/' S&*#'?9-"#*' JZZ!>0>J' L99"$.';4A):49'S&*#*'G4%'G$#)49#' JZ]!>0>B' G&-".$#)&9'LA4'()*#%)3"#)&9'$95'S$*42[)95)9A' JZ]!>0>K' H&#$.'R$%A)9$.'S&*#*'G4%'S$-)#$' JZg
table of contents xiii
!>Z' ,7-4%#49*)&9'S&*#'R&54.*' JZg!>Z>/' S&*#'?9-"#*' JZg!>Z>J' L99"$.';4A):49'S&*#*'G4%'G$#)49#.' JZg!>Z>B' G&-".$#)&9'LA4'()*#%)3"#)&9'$95'S$*42[)95)9A' JZd!>Z>K' H&#$.'R$%A)9$.'S&*#*'G4%'S$-)#$' JZd
!>]' S8%&9)+';4*-)%$#&%7'()*4$*4'S&*#'R&54.*' J]1!>]>/' S&*#'?9-"#*' J]1!>]>J' L99"$.';4A):49'S&*#*'G4%'G$#)49#' J]1!>]>B' G&-".$#)&9'LA4'()*#%)3"#)&9'$95'S$*42[)95)9A' J]1!>]>K' H&#$.'R$%A)9$.'S&*#*'G4%'S$-)#$' J]/
!>g' U-).4-*7'S&*#'R&54.*' J]/!>g>/' S&*#'?9-"#*' J]/!>g>J' L99"$.';4A):49'S&*#*'G4%'G$#)49#' J]/!>g>B' G&-".$#)&9'()*#%)3"#)&9'$95'S$*42[)95)9A' J]/!>g>K' H&#$.'R$%A)9$.'S&*#*'G4%'S$-)#$' J]J
appendix cIndicators for Monitoring and Evaluation 271S>/' ,4$%#'[$)."%4'$95'G&*#2S$%5)$+'Y"%A4%7'[&..&<2a-' J]/
S>J' S$%5)$+'Y"%A)+$.';464%%$.'$95'S$*4'Y4.4+#)&9' J]B
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appendix dForms 281(>/' ?9#$P4'[&%:*' Jg/
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xiv chronic care integration for endemic non-communicable diseases
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table of contents xv
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xvi chronic care integration for endemic non-communicable diseases
Tables
chapter 1HL!FU'/>/' !"%549'&6'`&92S&::"9)+$3.4'()*4$*4*')9';<$95$'F)9P45'
#&'S&95)#)&9*'&6'G&@4%#7' JHL!FU'/>J' F4$5)9A'S$"*4*'&6'(4$#8'$95'()*$3).)#7')9';<$95$')9''
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chapter 2HL!FU'J>/' S&*#i?:-$+#'R$#%)E'&6'R45)+$.'?9#4%@49#)&9*C''
<)#8'UE$:-.4*' /dHL!FU'J>J' Y7:-#&:'L**4**:49#'Y+$.4'VL5$-#45'6%&:'#84'L6%)+$9'
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chapter 4HL!FU'K>/' S$"*4*'&6',4$%#'[$)."%4';4-&%#45'37'Y4.4+#45''
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table of contents xvii
HL!FU'K>/0' R&%#$.)#72;45"+)9A'R45)+$#)&9*'6&%'S$%5)&:7&-$#87' Z]HL!FU'K>/Z' ()A&E)9'(&*)9A' ]BHL!FU'K>/]' L9#)87-4%#49*)@4*'6&%',7-4%#49*)@4',4$%#'()*4$*4' ]ZHL!FU'K>/g' R45)+$#)&9*'#&';45"+4',4$%#';$#4')9'R)#%$.'Y#49&*)*' g1HL!FU'K>/d' R45)+$#)&9*'6&%'\$.@".$%iS&9A49)#$.',4$%#'()*4$*4' g0HL!FU'K>J1' S.)9)+$.'G%4*49#$#)&9'&6';)A8#2Y)545',4$%#'[$)."%4' g]HL!FU'K>J/' S$"*4*'&6';)A8#2Y)545',4$%#'[$)."%4' ggHL!FU'K>JJ' H%4$#:49#'&6'H"34%+".&"*'G4%)+$%5)#)*')9'L5".#*' dJHL!FU'K>JB' S.)9)+'[&..&<2a-'Y+845".4'6&%',4$%#'[$)."%4'G$#)49#*' dZ
chapter 5HL!FU'0>/' H7-)+$.'G%4&-4%$#)@4'U@$."$#)&9'6&%'S$%5)$+'Y"%A4%7' //BHL!FU'0>J' H7-4*'&6'\$.@4';4-$)%*' //0HL!FU'0>B' H7-4*'&6';4-.$+4:49#',4$%#'\$.@4*' //]HL!FU'0>K' U:-)%)+'L9#)3)&#)+'H%4$#:49#*'6&%'U95&+$%5)#)*' /J/
'\$.@4'U95&+$%5)#)*' /JB
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chapter 6HL!FU'Z>/' S$"*4*'&6'U952Y#$A4';49$.'()*4$*4')9'Y"32Y$8$%$9''
L6%)+$'$95'#84'a>Y>' /B0HL!FU'Z>J' ;4.$#)&9*8)-'34#<449'a%)94'()-*#)+P'$95'JK28&"%''
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chapter 7HL!FU']>/' ()$34#4*'()$A9&*)*W'!.&&5'Y"A$%'R4$*"%4:49#''
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xviii chronic care integration for endemic non-communicable diseases
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chapter 8HL!FU'g>/' ,)A82;)*P'[4$#"%4*')9',7-4%#49*)&9' /dBHL!FU'g>J' ?9)#)$#)&9'&6',7-4%#49*)&9'H%4$#:49#'L++&%5)9A'#&''
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chapter 9HL!FU'd>/' S.)9)+$.'(4+)*)&9';".4*'6&%'H%4$#:49#'&6'G8$%79A)#)*' JJ1
table of contents xix
HL!FU'd>J' L9#)3)&#)+';4A):49*'6&%'Y#%4-#&+&++$.'G8$%79A)#)*''VL5".#*'$95'L5&.4*+49#*'(&*)9AC'_4)A8#' 'J]'PAX' JJJ
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chapter 10HL!FU'/1>/' U@$."$#)&9'&6'L*#8:$'L##$+P'Y4@4%)#7'VL5$-#45'6%&:'
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HL!FU'/1>B' S&::&9'Y)A9*'$95'Y7:-#&:*'&6'L*#8:$' JK/
HL!FU'/1>0' 'L*#8:$'S&9#%&.'H4*#' JKBHL!FU'/1>Z' L*#8:$'Y#4-'H84%$-7' JKZHL!FU'/1>]' L*#8:$'R45)+$#)&9'(&*)9A' JK]
xx chronic care integration for endemic non-communicable diseases
Protocols
chapter 4G;bHbSbF'K>/' ?9)#)$.'()$A9&*)*'$95'R$9$A4:49#'&6',4$%#'[$)."%4' 0KG;bHbSbF'K>J' R$9$A4:49#'&6'(4+&:-49*$#45',4$%#'[$)."%4' 0gG;bHbSbF'K>B' \&.":4'Y#$#"*'L**4**:49#'$95'()"%4#)+'L5D"*#:49#' Z1G;bHbSbF'K>K' S$%5)&:7&-$#87'R$9$A4:49#' Z0G;bHbSbF'K>0' !4#$2!.&+P4%'H)#%$#)&9')9'S$%5)&:7&-$#87' ZdG;bHbSbF'K>Z' LSU2?98)3)#&%'H)#%$#)&9'$95'a*4'&6''
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chapter 5G;bHbSbF'0>/' R$9$A4:49#'&6'[4@4%')9'G$#)49#*'<)#8'G%&*#84#)+''
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table of contents xxi
chapter 6G;bHbSbF'Z>/' ?9)#)$.'U@$."$#)&9'&6'S8%&9)+'M)5947'()*4$*4''
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chapter 8G;bHbSbF'g>/' ?9)#)$.'Y+%449)9A'$95'R$9$A4:49#'&6',7-4%#49*)&9''
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xxiv chronic care integration for endemic non-communicable diseases
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References
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abbreviations
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chapter 1Integration of Chronic Care Services in Rwanda
1.1 The Long Tail of Endemic Non-Communicable Diseases in Rwanda
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2 chronic care integration for endemic non-communicable diseases
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TABLE 1.1 Burden of Non-Communicable Diseases in Rwanda Linked to Conditions of Poverty
Condition Risk factors related to poverty
Hematology and oncology4-7
Cervical cancer, gastric cancer, lymphomas, Karposi’s sarcoma, hepatocellular carcinoma
HPV, H. Pylori, EBV, HIV, Hepatitis B
Breast cancer, CML Idiopathic, treatment gap
Hyperreactive malarial splenomegaly, hemoglobinopathies
Malaria
Psychiatric8 Depression, psychosis, somatoform disorders
War, untreated chronic diseases, undernutrition
Schizophrenia, bipolar disorder Idiopathic, treatment gap
Neurological9-11 Epilepsy Meningitis, malaria
Stroke Rheumatic mitral stenosis, endocarditis, malaria, HIV
Cardiovascular12-14 Hypertension Idiopathic, treatment gap
Pericardial disease Tuberculosis
Rheumatic valvular disease Streptococcal diseases
Cardiomyopathies HIV, other viruses, pregnancy
Congenital heart disease Maternal rubella, micronutrient deficiency, idiopathic, treatment gap
Respiratory14,15 Chronic pulmonary disease Indoor air pollution, tuberculosis, schisto-somiasis, treatment gap
Renal16 Chronic kidney disease Streptococcal disease
Endocrine17 Diabetes Undernutrition
Hyperthyroidism and hypothyroidism Iodine deficiency
Musculoskeletal18,19 Chronic osteomyelitis Bacterial infection, tuberculosis
Musculoskeletal injury Trauma
Vision20 Cataracts Idiopathic, treatment gap
Refractory error Idiopathic, treatment gap
Dental21 Caries Hygiene, treatment gap
chapter!1 | integration of chronic care services in rwanda 3
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TABLE 1.2 Leading Causes of Death and Disability in Rwanda in Disability-Adjusted Life Years (DALYs)24
Disease DALYs (’000)
Fraction of total DALYs
Lower respiratory infections 843 15.6%
74%
Diarrheal diseases 633 11.7%
HIV/AIDS 557 10.3%
Maternal conditions 278 5.2%
Malaria 277 5.1%
Neonatal infections and other conditions 252 4.7%
Birth asphyxia and birth trauma 237 4.4%
Tuberculosis 187 3.5%
Other infectious diseases (meningitis, STDs excluding HIV, childhood-cluster diseases, upper respiratory infections, Hepatitis B, Hepatitis C)
180 3.3%
Tropical-cluster diseases 170 3.2%
Prematurity and low birth weight 155 2.9%
Protein-energy malnutrition 128 2.4%
Nutritional deficiencies 102 1.9%
Congenital anomalies
Unipolar depression
Asthma
EpilepsyDiabetes mellitus
COPD
Cervical cancerLymphomas
Rheumatic heart disease
Myocarditis
4 chronic care integration for endemic non-communicable diseases
FIGURE 1.1 The Long Tail of Endemic NCDs in Rwanda
1.2 A Framework for Strategic Planning for Endemic Non-Communicable Disease
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8$%:'#8$9'A&&5'34+$"*4'#847'+$9'5)@4%#'-%4+)&"*':$9-&<4%'$95'6"95*'6%&:':&%4'-%4@$.49#'84$.#8'-%&3.4:*>
Referral centers (1 per 5–10
million people)
District hospitals (1 per 250,000
people)
Health centers(1 per 20,000
people)
Community health workers
(1 per 200 people)
Health facilities
Integratedchronic care
Integrated gynecology(benign and malignant)
PathologyCardiac surgery
Cancer center
Medical specialties
Surgical specialties Radiology
2nd-level acute care generalist physicians
chapter!1 | integration of chronic care services in rwanda 5
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S8%&9)+'+$%4')9#4A%$#)&9')*'&94'&6'#84'"9)#*'6&%'*#%$#4A)+'-.$99)9A'#8$#'-%&3$3.7':$P4*'*49*4')9'*&:4'&6'#84'-&&%4*#'84$.#8'*7*#4:*>'H84%4'$%4':$97'T%'"9)#*'#8$#'$%4'+%"+)$.'#&'+$%4'$95'+&9#%&.'&6'4954:)+'`S(*'V*44'FIGURE 1.2X>'H84*4')9+."54'%464%%$.2.4@4.'6"9+#)&9*'*"+8'$*'8)*#&-$2#8&.&A7'$95'+$%5)$+'*"%A4%7C'$*'<4..'$*'5)*#%)+#'8&*-)#$.k.4@4.'*4%@)+4'3"95.4*'*"+8'$*')9#4A%$#45'A794+&.&A)+'*4%@)+4*'V)9+."5)9A'+4%@)+$.'$95'3%4$*#'+$9+4%'*+%449)9AX>'H8)*'8$953&&P'6&+"*4*'&9'+8%&9)+'+$%4')9#42
FIGURE 1.2 Units of Planning for the Long-Tail Endemic NCDs
6 chronic care integration for endemic non-communicable diseases
1.3 Decentralization and Integration of Chronic Care for Non-Communicable Disease in Rwanda
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chapter!1 | integration of chronic care services in rwanda 7
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1.4 Which Chronic Diseases?
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1.5 The District Hospital as a Source of Clinical Leadership
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8 chronic care integration for endemic non-communicable diseases
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?9)#)$..7C'<4'#%$)945'$5@$9+45'9"%*4*'$#'5)*#%)+#'+.)9)+*'#8%&"A8'5$).7C'5)%4+#'-$#)49#':$9$A4:49#'<)#8'-87*)+)$9*>'L*'#84'-%&A%$:'A%4<C'<4'6&%:$.)^45'#8)*'-%&+4**')9#&'$'#8%442:&9#82.&9A'#%$)9)9A'+"%%)+".":')9'$5@$9+45'+8%&9)+'5)*4$*4':$9$A4:49#'$95'3$*)+'4+8&+$%5)&A%$-87>'H84'-%&A%$:')9+."54*'3'5)5$+#)+'$95'-%$+#)+$.'#%$)9)9A'37'-87*)+)$9*'$95'-%4@)&"*.7'#%$)945'$5@$9+45'9"%*4*>
L#'#84'*$:4'#):4C'$9'466&%#'#&'54@4.&-'$'#%$)9)9A'*#%$#4A7'6&%'84$.#8'+49#4%k.4@4.'+.)9)+)$9*'%4O")%45'A%4$#4%'+&&%5)9$#)&9'&6'+8%&9)+'+$%4'*4%@)+4*>'?9'#8)*':&54.C'-%&A%$:'.4$54%*')9'`S(*C'94"%&-*7+8)$#%7C'$95')964+#)&"*'5)*4$*4*'V,?\'$95'H!X'6&%:'$'+8%&9)+'+$%4'#4$:'#8$#'#%$)9*'$95':49#&%*'$'A%&"-'&6'84$.#82+49#4%'+.)9)+)$9*')9'#84'3$*)+':$9$A4:49#'&6'#84*4'+&95)#)&9*'V*44'FIGURE 1.3X>'TABLE 1.3 -%&@)54*'$'*$:-.4'*+845".4'&6'#84'+.)9)+$.'$95'#%$)9)9A'5"#)4*'&6'5)*#%)+#2.4@4.'+.)9)+)$9*>
Specialist physicians (1–2 per
specialty)
Generalist physicians
(4–10)
NCD nurses
(2–3)
HIV and TB nurses
(4–5)
Neuro-psychiatric
nurses(2–3)
Integrated chronic care nurses (2–3)
Integrated chronic care CHWs (2)
Health Workers(Number per Facility)
Referral centers (1 per 5–10
million people)
District hospitals (1 per 250,000
people)
Health centers(1 per 20,000
people)
Community health workers
(1 per 200 people)
Health facilities
TABLE 1.3 Sample District Hospital–Based Clinician Schedule
Monday Tuesday Wednesday Thursday Friday
Nurse 1 Preceptorship of health center nurses
Teaching (didactics)
District hospital heart failure clinic and preceptorship
Teaching (didactics)
Administration
Nurse 2 District hospital hematology/ oncology and preceptorship
District hospital chronic respiratory disease and preceptorship
Teaching (didactics)
District hospital advanced diabetes and hypertension clinic and preceptorship
Teaching (didactics)
chapter!1 | integration of chronic care services in rwanda 9
FIGURE 1.3 Integration of Human Resources for Chronic Care
10 chronic care integration for endemic non-communicable diseases
1.6 District Inpatient Care
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1.7 Health Centers: Case Finding, Initial Management, and Chronic Care
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chapter!1 | integration of chronic care services in rwanda 11
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$+#)@)#)4*>'(4+49#%$.)^$#)&9'&6'+.)9)+$.'*4%@)+4*'$.*&'%4O")%4*'4*#$3.)*82:49#'&6'5%"A'*"--.7'+8$)9*'#8$#')9+."54'#84'84$.#82+49#4%'6$+).)#)4*>'
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1.8 Referral Centers
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54.)@4%7'&6'$+"#4'$95'+8%&9)+'+$%4'6&%'-$#)49#*'<)#8'9&92+&::"9)+$3.4'5)*4$*4*C'%464%%$.'+49#4%*'+$9'6&+"*'&9'#8&*4'$+#)@)#)4*'34*#'-%&@)545'$#'#84'#4%#)$%7'.4@4.>'H84*4')9+."54'*-4+)$.#7'+&9*".#$#)&9'6&%'+&:-.4E'4925&+%)94'+$*4*h'4+8&+$%5)&A%$-87'$95'+$%5)$+'*"%A4%7'6&%'%84":$#)+'$95'+&9A49)#$.'84$%#'5)*4$*4h'-$#8&.&A)+'5)$A9&*)*C'*"%A4%7C'+84:T%$-7C'$95'%$5)$#)&9'6&%':$.)A9$9+)4*h'$95'+&:-"#4%)^45'#&:&A%$-87'$95'
&"#%4$+8'37'*-4+)$.)*#*'6%&:'%464%%$.'+49#4%*'#&'5)*#%)+#'8&*-)#$.*')9'*"+8'$'<$7'$*'#&'-%&:'-"3.)+'$95'A&@4%9:49#$.'*"--&%#'6&%'*#%49A#849)9A'#84'9$#)&9$.'84$.#8'*7*#4:>
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12 chronic care integration for endemic non-communicable diseases
1.9 Out-of-Country Referral
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1.10 Screening
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#84'@4%7'.4$*#C'+&::"9)#7'84$.#8'<&%P4%*'49A$A45')9'$+"#4'+$%4'*8&".5'34'#%$)945')9'%4+&A9)^)9A'#84'*7:-#&:*'$95'*)A9*'&6'54+&:-49*$#45'+8%&9)+'5)*4$*4*>'Y+%449)9A'&9.7':$P4*'*49*4C'8&<4@4%C')9'$'*4##)9A''<)#8'4*#$3.)*845'$95'4664+#)@4'+8%&9)+'+$%4'*4%@)+4*>'
1.11 Principles of Patient Follow-Up and Retention: Community Health Workers and the Electronic Medical Record
S8%&9)+'+$%4'*4%@)+4*')9'$97'*4##)9A'*#%"AA.4'#&'$+8)4@4'A&&5'-$#)49#'6&..&<2"-'$95'%4#49#)&9>'_8).4'5)%4+#.7'&3*4%@45'#84%$-7'6&%',?\'#%4$#:49#'%4:$)9*'+&9#%&@4%*)$.C'G?,2*"--&%#45',?\'-%&A%$:*'8$@4'$+8)4@45'4E+4-#)&9$.'-$#)49#'%4#49#)&9'$95'+.)9)+$.'&"#+&:4*>B0'?9'#8)*'*7*#4:C'+&::"9)#7'84$.#8'<&%P4%*C'&%'(55$-1(>4(,'.#*C'@)*)#'-$#)49#*'&9'$'5$).7'3$*)*'#&'-%&@)54'-*7+8&*&+)$.'*"--&%#C'$5:)9)*#4%':45)+$2
$--&)9#:49#*>'_4'8$@4'$5&-#45'$'*):).$%':&54.'6&%'-$#)49#*'<)#8'T%'$5@$9+45'+8%&9)+'+&95)#)&9*C'*"+8'$*'84$%#'6$)."%4C')9*".)9254-49549#'5)$34#4*C'$95':$.)A9$9+)4*>'H84'84$.#8'<&%P4%*'$.*&'*4%@4'$*'$'.)9P'342
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6$+).)#$#4*'3'-$#)49#'6&..&<2"-'$95'-%&A%$:'4@$."$#)&9'$95':&9)#&%)9A>'
chapter!1 | integration of chronic care services in rwanda 13
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1.12 Equipment, Medication Procurement, and Costs
H84'_,b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h'#847'*8&".5'-%&@)54'+8%&9)+$..7'$5:)9)*#4%45':45)+$#)&9*'6%44'&%'$#':)9):$.'+8$%A4'#&'-$#)49#*'$#'#84'-&)9#'&6'+$%4>'APPENDIX B-%&A%$:'+&*#*'6&%'4$+8'+&95)#)&9>
14 chronic care integration for endemic non-communicable diseases
Chapter 1!References
/' RULYa;U'(,Y'bR>';<$95$'(4:&A%$-8)+',4$.#8'Y"%@47'???>'J110W';<$95$h'J110>
J' RULYa;U'(,Y'bR>'?9#4%):';<$95$'(4:&A%$-8)+',4$.#8'Y"%@47>'J11]21gW';<$95$h'J11d>
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chapter!1 | integration of chronic care services in rwanda 15
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Disease-specific therapy
Diagnosis Death
Palliative careBereavement
chapter 2Palliative Care and Chronic Care
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FIGURE 2.1 Diagram of Palliative Care throughout the Course of Illness and Bereavement (Adapted from WHO)1
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18 chronic care integration for endemic non-communicable diseases
2.1 History and Philosophy of Palliative Care E"orts in Resource-Poor Settings
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2
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chapter!2 | palliative care and chronic care 19
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TABLE 2.1 Cost/Impact Matrix of Medical Interventions, with Examples
High impact of therapy Low, marginal impact of therapy
High cost multidrug-resistant TB
cardiomyopathy
medications
Low cost without high-risk features
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2.2 Community Health Workers and Common Palliative Care Interventions in the Treatment of Chronic Disease
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20 chronic care integration for endemic non-communicable diseases
#&'3%4$P'#8)*'-$##4%9'37')9#4A%$#)9A'-$..)$#)@4'+$%4')9#&'+8%&9)+'+$%4'*4%2@)+4*'$#'#84'5)*#%)+#28&*-)#$.C'84$.#82+49#4%C'$95'+&::"9)#7'.4@4.>
?9'#8)*':&54.C'$'+49#%$.'-$..)$#)@4'+$%4'"9)#'<)..'-%&@)54'&@4%*)A8#C')9+."52)9A'#%$)9)9AC':&9)#&%)9AC'$95'*"-4%@)*)&9>'?#'$.*&'<)..'49*"%4'3'#8$#'&-)&)5'-$)9':45)+$#)&9')*'$++4**)3.4'37'$97&94')9'9445'$95'#8$#'#84'%)*P'&6'&-)&)5'5)@4%*)&9'6&%')..)+)#'-"%-&*4*')*':)9):)^45>'H8)*'"9)#':$7'34'.&+$#45'<)#8)9'"9)@4%*)#7'#4$+8)9A'8&*-)#$.*>'L#'5)*#%)+#'[email protected]'-$.2.)$#)@4'+$%4'<)..'34')9#4A%$#45')9#&'4E)*#)9A'6"9+#)&9*'&6'-87*)+)$9*'$95'$5@$9+45'`S('9"%*4*>'G87*)+)$9*'<)..'-4%6&%:')9)#)$.'4@$."$#)&9*'&6'-$2#)49#*')9'9445'&6'8&:423$*45'-$..)$#)@4'+$%4'$95'-%4*+%)34':45)+$#)&9*C')9+."5)9A'&%$.':&%-8)94>'`S('9"%*4*'<)..'#849'34'+8$%A45'<)#8':&9)#&%2)9A'#84*4'-$#)49#*'$95'<)#8'-%&@)5)9A'&@4%*)A8#'&6'84$.#8'+49#4%k3$*45'9"%*4*>'L#'#84'84$.#82+49#4%'[email protected]'9"%*4*'<)..'$5D"*#'-%4*+%)-#)&9*'$95'-%&@)54'&@4%*)A8#'$95'#%$)9)9A'#&'#84'+&::"9)#7'84$.#8'<&%P4%*>'L..'4**49#)$.'-$..)$#)@4'+$%4':45)+$#)&9*'*8&".5'34'$@$).$3.4'$#'#84'84$.#82+49#4%'.4@4.')9'&%54%'#&':$E):)^4'-$#)49#'$++4**>'L#'#84'+&::"9)#7'[email protected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
2.2.1 Assessment of SymptomsH%"4')9#4A%$#)&9'&6'-$..)$#)&9'<)#8)9'$':&54.'&6'+8%&9)+'5)*4$*4'+$%4')9+."54*'$'#8&%&"A8'$**4**:49#'&6'-87*)+$.'$95'-*7+8&*&+)$.'5)*#%4**'$#'#84'#):4'&6'5)*4$*4'5)$A9&*)*>'H84*4'4.4:49#*'*8&".5'34'%4@)4<45'&9'4$+8'%4#"%9'@)*)#'$*'-$%#'&6'#84'$**4**:49#'&6'5)*4$*4'+&9#%&.>'H84'9445*'&6'#84'6$:).7':4:34%*'84.-)9A'#&'+$%4'6&%'#84'-$#)49#'$.*&'*8&".5'34'$*2*4**45')9#4%:)##49#.7>'b6#49C'-$..)$#)@4'466&%#*'<)..')9+."54'54.)@4%)9A':$2#4%)$.'*"--&%#'#&'6$:).)4*'):-&@4%)*845'37'#84'-$#)49#=*')..94**C')9+."5)9A'84.-'<)#8'8&"*)9AC'6&&5C'$95'*+8&&.'644*>'L55%4**)9A'#84'*&+)$.'9445*'&6'#84*4'-$#)49#*'$95'#84)%'6$:).)4*'%4O")%4*'+&&%5)9$#)&9'<)#8'A&@4%9:49#':)9)*#%)4*'49A$A45')9'$A%)+".#"%4C'45"+$#)&9C'$95'*&+)$.'<4.6$%4>
G$..)$#)@4'+$%4'%4*4$%+84%*'8$@4'54@4.&-45'$'@$.)5$#45'O"4*#)&99$)%4C'<8)+8'8$*'3449'#4*#45')9'%"%$.'*"32Y$8$%$9'L6%)+$9'*4##)9A*'V*44'TABLE 2.2X>/B'H84*4'O"4*#)&9*'<)..'9&#'34'$--.)+$3.4'6&%'$..'-$#)49#*'<)#8'+8%&9)+'
chapter!2 | palliative care and chronic care 21
)..94**C'*"+8'$*'#8&*4'<)#8':).5'$*#8:$'&%'87-4%#49*)&9>'_4'8$@4')9+&%-&%$#45'#84*4'O"4*#)&9*')9#&'&"%'+.)9)+$.'6&%:*'<84%4'$--%&-%)$#4')9'#84';<$95$9'`S('+.)9)+*>'_4'$%4')9'#84'-%&+4**'&6'54@4.&-)9A':&%4'
37'+&::"9)#7'84$.#8'<&%P4%*>
TABLE 2.2 Symptom Assessment Scale (Adapted from the African Palliative Outcomes Scale)13
Questions for patient:
Q1. Please rate your pain during the last 3 days 0 (no pain) – 5 (worst/overwhelming pain)
Q2a. Have any other symptoms (e.g., nausea, coughing, or constipation) been a#ecting how you feel in the last 3 days?
Q2b. If so, please rate each symptom during the last 3 days: Dyspnea? Nausea or vomiting? Constipation? Diarrhea? Others? (specify)
0 (no, not at all) – 5 (overwhelmingly)
0 (no, not at all) – 5 (overwhelmingly)0 (no, not at all) – 5 (overwhelmingly)0 (no, not at all) – 5 (overwhelmingly)0 (no, not at all) – 5 (overwhelmingly)0 (no, not at all) – 5 (overwhelmingly)
Q3. Have you been feeling worried about your illness in the past 3 days?
0 (no, not at all) – 5 (overwhelming worry)
Q4. Over the past 3 days, have you been able to share how you are feeling with your family or friends?
0 (no, not at all) – 5 (yes, I’ve talked freely)
Q5. Over the past 3 days, have you felt that life was worthwhile?
0 (no, not at all) – 5 (yes, all the time)
Q6. Over the past 3 days, have you felt at peace? 0 (no, not at all) – 5 (yes, all the time)
Q7. Over the past 3 days, have you had enough help and advice for your family to plan for the future?
0 (no, not at all) – 5 (as much as wanted)
Questions for family caregiver:
Q8. Over the past 3 days, how much information have you and your family been given?
0 (none) – 5 (as much as wanted)N/A
Q9. Over the past 3 days, how confident has the family felt caring for the patient?
0 (not at all) – 5 (very confident)N/A
Q10. Has the family been feeling worried about the patient over the last 3 days?
0 (not at all) – 5 (severe worry)N/A
2.2.2 Symptom Management
&%':&%4'+&::&9C'5)*#%4**)9A'*7:-#&:*>'H84%$-)4*'$):45'$#'#84*4'
#%4$#:49#'$.A&%)#8:*>',4%4'<4'#&"+8'&9'*&:4'&6'#84'-%)9+)-.4*'&"#.)945')9'#84'?9#4A%$#45'R$9$A4:49#'&6'L5".#'$95'L5&.4*+49#'?..94**'G$..)$2#)@4'S$%4'T")54.)94'R&5".4C'#84'\)4#9$:'R)9)*#%7'&6',4$.#8'T")54.)94*'&9'G$..)$#)@4'S$%4'6&%'S$9+4%'$95'L?(Y'G$#)49#*C'$95'#84',&*-)+4'L6%)+$'aA$95$'G$..)$#)@4'R45)+)94'T")54>JC0C/J'S84:T%$-7'$95'%$5)$#)&9'#84%$-7C'3'&6'<8)+8'8$@4'):-&%#$9#'%&.4*')9'%4.)4@)9A'-$)9'$95'T%'
22 chronic care integration for endemic non-communicable diseases
*7:-#&:*'5"4'#&'+$9+4%C'<)..'34'$55%4**45')9'$'6&%#8+&:)9A':$9"$.'&9'+$9+4%'+$%4'$95'+&9#%&.>
2.2.3 PainG$)9'$++&:-$9)4*':$97'+8%&9)+'5)*4$*4*'$95')*'$':$D&%'+$"*4'&6'5)*2$3).)#7'$95'*"664%)9A>',&<4@4%C'$++4**'#&'-$)9'%4.)46'#7-)+$..7')*'.):)#45'&%'9&94E)*#49#')9'%4*&"%+42-&&%'*4##)9A*>'R$97'+&"9#%)4*'*4@4%4.7'%4*#%)+#'#84'"*4'&6':&%-8)94'&"#'&6'64$%'&6'&-)&)5'5)@4%*)&9'&%'#84'+%4$#)&9'&6'$55)+#)&9'$:&9A'-$#)49#*>'L'J11K'*#"57'37'#84'?9#4%9$#)&9$.'`$%+&#)+*'S&9#%&.'!&$%5'%4@4$.45'#8$#'+&"9#%)4*'<)#8'g1m'&6'#84'<&%.5=*'-&-"2.$#)&9'+&:-%)*45'&9.7'Zm'&6'#84'<&%.5=*'#&#$.'&-)&)5'+&9*":-#)&9>/K',&<4@4%'*4@4%$.'+&"9#%)4*')9'*"32Y$8$%$9'L6%)+$C')9+."5)9A'aA$95$C'Y&"#8'L6%)+$C'$95';<$95$'8$@4'$5&-#45'-&.)+)4*'#&')9+%4$*4'$++4**'#&'&-)$#4*>/0C/Z
H84%4'$%4'#<&':$D&%'+$#4A&%)4*'&6'+8%&9)+'-$)9C'<8)+8'&6#49'%4O")%4'5)6264%49#'#84%$-)4*>
2.2.3.1 Nociceptive Pain`&+)+4-#)@4'-$)9')*'+$"*45'37'#84'*#):".$#)&9'&6'-$)9'%4+4-#&%*'$#'#84'495'&6'9&%:$.'*49*&%7'94%@4*'#8$#':45)$#4'-$)9>'`&+)+4-#)@4'-$)9')*'6"%2#84%'*"35)@)545')9#&'*&:$#)+'$95'@)*+4%$.'-$)9>'Y&:$#)+'%4+4-#&%*')9'#84'*P)9C'*&6#'#)**"4*C':"*+.4C'&%'3&94'$%4'*#):".$#45C'$95'#84'%4*".#)9A'-$)9'"*"$..7')*'4$*7'6&%'#84'-$#)49#'#&'.&+$.)^4'$95'54*+%)34>'G$)9')9'#84'*P)9')*'&6#49'*8$%-C'3"%9)9AC'&%'#8%&33)9A>'G$)9')9'#84':"*+.4')*'&6#49'A9$<)9A'&%'5"..>'G$)9')9'#84'3&94')*'$.*&'A9$<)9A'$95'5"..C'3"#'+$9'34+&:4'*8$%-'<)#8':&@4:49#>'\)*+4%$.'-$)9'#7-)+$..7')*'9&#'.&+$.)^45C'3"#':&%4'5)66"*4C'$95':$7'34'%464%%45'#&'$'*)#4'5)*#$9#'6%&:'#84'.4*)&9>'?#':$7'34'5"..'&%'*8$%-'$95':$7'-%&5"+4'$'644.)9A'&6'-%4**"%4>'?#')*'+$"*45'37'*#):".$#)&9'&6'-$)9'%4+4-#&%*')9')9#4%9$.'&%A$9*C')9+."5)9A'8&..&<'@)*+4%$>'?#':$7'34'5"4'#&'3.&+P$A4C'*<4..)9AC'&%'*#%4#+8)9A'&6'#84'&%A$9*'5"4'#&':4#$*#$*4*C'
2.2.3.2 Neuropathic Pain`4"%&-$#8)+'-$)9')*'+$"*45'37'5$:$A4'#&'94%@4*'&%'3%$)9>'`4"%&-$#8)+'-$)9')*'&6#49'54*+%)345'$*'3"%9)9A'&%'.)P4'$9'4.4+#%)+'*8&+P>'H84%4'$.*&'+$9'34'9":394**C'#)9A.)9AC'&%'$..&579)$'V-$)9'%4*".#)9A'6%&:'$'*#):"."*'#8$#'9&%:$..7')*'9&#'-$)96".C'*"+8'$*'.)A8#'#&"+8X')9'#84'$%4$')994%@$#45'37'#84')9D"%45'94%@4*>'H8)*'#7-4'&6'-$)9')*'@4%7'+&::&9'$:&9A'&"%'5)$234#)+C'+$9+4%C'$95',?\iL?(Y'-$#)49#*>'L97'P)95'&6')9D"%7'#&'94%@4'#)**"4'
#":&%C')*+84:)$'6%&:'-&&%'+)%+".$#)&9'V)9'5)$34#4*':4..)#"*XC')964+#)&9'37'@$%)+4..$'^&*#4%'&%',?\'@)%"*C'&%'94"%&#&E)+':45)+$#)&9*C'*"+8'$*'*&:4'+$9+4%'+84:T%$-7'5%"A*'$95'*&:4'L;\*C'4*-4+)$..7'5KH'V*#$@"5)94X>
chapter!2 | palliative care and chronic care 23
2.2.3.3 Principles of Pain ManagementH84'6&..&<)9A'-%)9+)-.4*'$%4'):-&%#$9#'#&'*"++4**6".'#%4$#:49#'&6'-$)9W/
>+2?@A28!#00B180)2)"*&B#0=*0C2="%%0#+2U*+$.$#)9A'#84%$-7'6%&:'$'9&92&-)&)5'V$+4#$:)9&-849i-$%$+4#$:&.C')3"-%&649C'&%'$*-)%)9X'#&'$'<4$P'
V8)A84%25&*4':&%-8)94X>'?9';<$95$C'$'<4$P'&-)&)5'*"+8'$*'+&54)94')*'9&#'<)54.7'$@$).$3.4C'$95'<4'#84%46&%4'*"3*#)#"#4'.&<25&*4':&%2-8)94>'H84'_,b'%4+&::495*'$'#8%442*#4-'$--%&$+8'#&'%4.)46'&6'-$)9>/'L++&%5)9A'#&'#84'_,bC'#8)*'*):-.4':4#8&5'+$9'%4.)4@4'g1mkd1m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
2$#4'&%'*4@4%4'-$)9'&6'$97'P)95C')9+."5)9A'94"%&-$#8)+'-$)9>',&<4@4%C'94"%&-$#8)+'-$)9'*&:4#):4*')*'9&#'%4.)4@45'37'&-)&)5'&%'9&92&-)&)5'#%4$#:49#>'?9'#8)*'*)#"$#)&9C'$5D"@$9#':45)+$#)&9*C'*"+8'$*'$:)#%)-#72.)94'&%'-8497#&)9C'+$9'34'"*46".>'?9'T%'*)#"$#)&9*C'$5D"@$9#':45)+$2#)&9*'+$9'34'"*45'#&'%45"+4'&%'4.):)9$#4'#84'9445'6&%'&-)&)5'#84%$-7>'[&%'4E$:-.4C'4@49'*4@4%4'-$)9'+$"*45'37'.)@4%':4#$*#$*4*'*&:4#):4*'+$9'34'%4.)4@45'<)#8'$'*#4%&)5C'*"+8'$*'-%459)*&.&94'&%'54E$:4#8$*&94>
FIGURE 2.2 The WHO Three-Step Pain Ladder1
Severe pain or pain persisting/increasingStrong opioid+/- non-opioid+/- adjuvant
Moderate pain or pain persisting/increasingWeak opioid (or low-dose strong opioid)+/- non-opioid+/- adjuvant
Mild painNon-opioid (paracetamol or NSAID)+/- adjuvant
24 chronic care integration for endemic non-communicable diseases
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
E+2A)*,*%28,=0#"&'0+'b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2#)&9*')9'#84'8&:4>'?9';<$95$C'.)O")5':&%-8)94'-%4-$%$#)&9*'<)..'34'5)*#%)3"#45'37'+&::"9)#7'84$.#8'<&%P4%*'6&..&<)9A')9)#)$.'-%4*+%)-2#)&9'37'$'-87*)+)$9>'F)O")5':&%-8)94')*':$54'6%&:'-&<54%')9'@$%)&"*'+&9+49#%$#)&9*'54-495)9A'&9'#84'-$#)49#=*'9445*>'VY44'APPENDIX A'6&%'&%$.':&%-8)94'%4+)-4*>X'_849'-$#)49#*'+$9'9&'.&9A4%'#&.4%$#4'&%$.':45)+$#)&9*C'3"++$.'&%'%4+#$.'%&"#4*':$7'34'"*45>'!4+$"*4'#84'$32*&%-#)&9'&6':&%-8)94'37'#84*4'%&"#4*')*'"9-%45)+#$3.4C'8)A84%'5&*4*':$7'34'%4O")%45>
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T%<)*4'$54O"$#4'-$)9'%4.)46>'_849'3%4$P#8%&"A8'-$)9'&++"%*C')#'*8&".5'34'#%4$#45'<)#8'$9'4E#%$'5&*4'&6'&-)&)5>'H84'%4*+"4'5&*4'*8&".5'34'/1m'&6'#84'#&#$.'JK28&"%'5&*4'&6'&-)&)5>'[&%'4E$:-.4C')6'$'-$#)49#'#$P)9A':&%-8)94'/1':A'&%$..7'4@4%7'K'8&"%*'8$*'3%4$P2#8%&"A8'-$)9C'*84'*8&".5'34'A)@49'$'Z':A'%4*+"4'5&*4>
I+2A)*,*%21*%020CC0'81+'R&*#'-$#)49#*'#$P)9A'$9'&-)&)5'54@4.&-'+&9*#)2-$#)&9>'H84%46&%4C'$'.&<'5&*4'&6'$'.$E$#)@4'*8&".5'34'-%4*+%)345'6&%':&*#'-$#)49#*'<849'&-)&)5'#84%$-7')*')9)#)$#45C'$95'#84'5&*4'*8&".5'
chapter!2 | palliative care and chronic care 25
34'$5D"*#45'$#'*"3*4O"49#'@)*)#*'3$*45'&9'#84'-$#)49#=*'-$##4%9'&6'3&<4.':&@4:49#*>'b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
*.44->';4*-)%$#&%7'54-%4**)&9')*'$'%$%4'*)54'4664+#'&6'&-)&)5'#84%$-7'<849'A")54.)94*'$%4'6&..&<45C'$95')#'94@4%'&++"%*'346&%4'*45$#)&9>'
TABLE 2.3'.)*#*'#84'4**49#)$.'-$)9':45)+$#)&9*'V3$*45'&9'#84';<$95$9'6&%:".$%7X'#8$#'*8&".5'34'$@$).$3.4'$#'#84'84$.#82+49#4%'.4@4.>
26 chronic care integration for endemic non-communicable diseases
TABLE 2.3 Essential Medications for Pain Relief
Symptom Medication Dose Notes
Mild pain/ fever reducers(non-opiates)
Acetaminophen/ paracetamol
Adult: 0.5–1 gram every 4 to 6 hours. Not to exceed 4 grams in 1 dayChild: 10-15 mg/kg (maximum 90 mg/kg/day divided every 4–6 hours)
Use maximum 2 grams per day in patients with enlarged livers or known liver disease. Very toxic to liver in overdose.
Ibuprofen Adult: 400–800 mg every 6-8 hours (maximum dose 2.4 gm/day)Child: 40 mg/kg/day every 6–8 hours
Particularly e#ective in bone pain. Anti-inflammatory at higher doses. Can cause digestive upset and gastrointestinal bleeding. Do not use in renal failure. Decrease doses in patients with severe liver failure. Prolonged prescription requires cimetidine or omepra-zole for gastrointestinal prophylaxis.
Diclofenac Adult: 25–75 mg every 12 hours
Same as ibuprofen, but less expensive for long-term use, with simpler dosing.
Moderate to severe pain
Morphine, liquid preparation
Adult: 2.5–10 mg every 4 hours. May give double dose at bedtime.No maximum dose. Titrate to patient comfort.Child: 0.15 mg/kg–0.3 mg/kg every 4 hours. Titrate as with adults.
Dose increases may be limited by oversedation.Should decrease the dose or increase the dosing interval in case of any renal failure.Constipation is a common problem and all patients should be placed on a bowel regimen prophylactically (see TABLE 2.5).
Neuropathic pain (burning pains or shooting)
Amitriptyline Adult: 10–25 mg by mouth daily.Child: 0.5 mg/kg once a day orally at bedtime. Increase as needed by 0.2–0.4 mg/kg every 2–3 days to maximum of 5 mg/kg/day.
Dose should be titrated upward every week to e#ect. May take weeks to work. Maximum dose in adults is 100 mg per day. Side e#ects include initial drowsiness, postural hypoten-sion, dry mouth, mild tachycardia, constipa-tion. Life-threatening cardiac toxicity with overdose.
Phenytoin Adult: 100 mg twice per day ini-tially, increase up to 400 mg twice per day if neededChild: 2.5–5 mg/kg twice per day (maximum 200 mg twice per day)
Can use instead of, or in addition to, amitrip-tyline if neuropathic pain persists. Avoid if on anti-retrovirals due to drug interactions.
Muscle spasms Diazepam Adult: 2.5–10 mg by mouth 2 to 3 times per dayChild: 0.05 mg/kg–0.1 mg/kg 3 to 4 times per day
Drowsiness, ataxia.
chapter!2 | palliative care and chronic care 27
Symptom Medication Dose Notes
Pain from swelling, inflammation, or neuropathy
Prednisolone Adult: 20–80 mg by mouth dailyChild: 1 mg/kg x 1–2x/day by mouth
May also improve nausea, fatigue, and appetite. Particularly helpful in the case of malignant lesions causing localized swelling in the muscle or bone. The dose should be decreased gradually over a period of 2–3 weeks and then stopped to avoid side e#ects.
2.2.4 Dyspnea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
2.2.5 Nausea/Vomiting`$"*4$'$95'@&:)#)9A'&++"%'<)#8':$97'+8%&9)+'5)*4$*4*C'4)#84%'$*'$'%4*".#'&6'#84'5)*4$*4'-%&+4**')#*4.6'&%'$*'$'*)54'4664+#'&6':45)+$#)&9*>'`$"*4$':$7'8$@4':$97'+$"*4*>'[&%')9*#$9+4C')9'84$%#C'.)@4%'$95'%49$.'6$)."%4C'#84'A"#'<$..*':$7'34+&:4'454:$#&"*'$95'6"9+#)&9'-&&%.7C'$'+&925)#)&9'#8$#'.4$5*'#&'9$"*4$'$95'@&:)#)9A>'`$"*4$2-%&5"+)9A'*"3*#$9+4*'#8$#'$%4'4)#84%'#$P49')9#&'#84'3&57'V*"+8'$*':45)+$#)&9*'&%'6&&5'#&E)9*X'&%'-%&5"+45'37'#84'3&57'V)9'.)@4%'&%'%49$.'6$)."%4C'6&%'4E$:-.4X'*#):".$#4'+4%#$)9'$%4$*'&6'#84'3%$)9'#8$#'+&9#%&.'9$"*4$'$95'@&:)#)9A>'TABLE 2.4')95)+$#4*'#84'$--%&-%)$#4'#84%$-7'6&%'9$"*4$'54-495)9A'&9'#84'+$"*4>'_849'-$#)49#*'+$99&#'#&.4%$#4'&%$.':45)+$#)&9C'#$3.4#*':$7'34'A%&"95'"-'$95':)E45'<)#8'<$#4%'6&%'%4+#$.')9*4%#)&9'@)$'$'*7%)9A4'<)#8&"#'$'9445.4>'
,$.&-4%)5&.'$95'-%&:4#8$^)94':$7'+$"*4'$'57*#&9)+'%4$+#)&9C'+8$%$+#4%2)^45'37':"*+.4'*-$*:*>'H8)*')*'"9+&:6&%#$3.4C'3"#'9&#'5$9A4%&"*C'$95'*8&".5'34'#%4$#45'<)#8'5)-849875%$:)94>
28 chronic care integration for endemic non-communicable diseases
TABLE 2.4 Essential Medications for Control of Nausea/Vomiting
Cause of nausea Therapy
Liver failure, renal failure, metabolic derangement, drug side e#ect, or bacterial infection (nausea due to a toxin or inflammatory mediator)
HaloperidolAdult: 0.5–1 mg 2–4 times per day given orally, IV, or SC, around the clock or as neededChild ( 40 kg): 0.025–0.05 mg/kg/day in 2–3 divided doses. Increase by 0.25–0.5 mg/day every 5–7 days as needed to maximum dose 0.15 mg/kg/day
PromethazineAdult: 12.5–25 mg every 4 hours orally, IV, IM, or by rectumChild ( 40 kg): 0.25–1 mg/kg 4 times a day orally, IV, IM, or by rectum. Maximum dose: 25 mg per dose
DexamethasoneAdult: 4–10 mg 2 times per day IV or IM, around the clock or as neededChild ( 40 kg): 0.5–1 mg/kg 2 times per day IV or SC around the clock or as needed. Maximum dose: 10 mg 2 times per day
Increased intracranial pressure, bowel obstruction, or distension of liver or of hollow viscus due to neoplasm
DexamethasoneAdult: 4–10 mg 2 times per day IV or IM, around the clock or as neededChild ( 40 kg): 0.5–1 mg/kg 2 times per day IV or SC around the clock or as needed. Maximum dose: 10 mg 2 times per day
Anxiety DiazepamAdult: 2.5–10 mg 3 times per day, orally, IV, or SC, around the clock or as neededChild ( 40 kg): 0.05–0.1 mg/kg/day divided 3–4 times per day
Gastroparesis Metoclopramide Adult: 10 mg, 4 times per day, orally, IV, or SC, around the clock or as needed.Child: 0.1-0.2 mg/kg/dose 4 times per day, orally, IV or SC, around the clock or as needed
Stimulation of vestibular apparatus
Chlorpheniramine Adult: 4 mg orally every 4 hours, around the clock or as neededChild ( 40 kg): 1–2 mg by mouth every 4–6 hours. Maximum dose: 6 mg/day for 2–5 yo, 12 mg/day for 6–11 yo, around the clock or as needed
PromethazineAdult: 12.5–25 mg every 4 hours orally, IV, IM, or by rectumChild: 0.25–1 mg/kg 4 times a day orally, IV, IM, or by rectum. Maximum dose: 25 mg
Adjuvants for nausea/ vomiting of any cause
ChlorpheniramineAdult: 4 mg orally every 4 hours, around the clock or as neededChild ( 40 kg): 1–2 mg by mouth every 4–6 hours. Maximum dose: 6 mg/day for 2–5 yo, 12 mg/day for 6–11 yo, around the clock or as needed
2.2.6 Constipation
*)54'4664+#'&6':45)+$#)&9*'&%'5"4'#&'#84'5)*4$*4')#*4.6>'?9'$55)#)&9C'+8%&9)2+$..7')..'-$#)49#*':$7'9&#'34'@4%7':&3).4'&%':$7'34'"9$3.4'#&'#&.4%$#4'
chapter!2 | palliative care and chronic care 29
L..'-$#)49#*'<)#8'+&9*#)-$#)&9'*8&".5'34'$**4**45'6&%'64+$.'):-$+#)&9'<)#8'$'5)A)#$.'%4+#$.'4E$:'$95'5)*):-$+#45':$9"$..7'$*'944545>'L..'
2$#45>'F$E$#)@4*'$95'494:$*':$7'$.*&'34'"*45'#&'4$*4'+&9*#)-$#)&9'V*44'TABLE 2.5X>'H84':&*#'+&::&9'#7-4*'&6'.$E$#)@4*'$%4'*#):".$9#*'V3)*$+&257.XC'&*:&#)+'$A49#*'V.$+#".&*4XC'$95'."3%)+$9#*'VA.7+4%)94X>'?9'-$#)49#*'<)#8'+&9*#)-$#)&9'5"4'-%):$%).7'#&'&-)&)5'#84%$-7C'$'*#):".$9#'.$E$#)@4')*'
$%4'<4..'875%$#45>'?9'*4@4%4'+$*4*'&6'&-)&)52)95"+45'+&9*#)-$#)&9C'&%$.'9$.&E&94'+$9'34'"*45'#&'%4@4%*4'#84'&-)&)5'4664+#'&9'#84'A"#>
G$#)49#*'<)#8')9#4%:)##49#'3&<4.'&3*#%"+#)&9'5"4'#&'$':$.)A9$9+7':$7'TABLE 2.3X>
2.2.7 Diarrhea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
$95'4.4+#%&.7#4*C')6'-&**)3.4'$95'$--%&-%)$#4>'_849'$'-$#)49#'#$P)9A'$'.$E$#)@4'54@4.&-*'5)$%%84$C'#84'.$E$#)@4'*8&".5'34'5)*+&9#)9"45'"9#).'#84'5)$%%84$'*#&-*>
TABLE 2.6'&"#.)94*'#84'4@$."$#)&9'$95'#%4$#:49#'&6'5)$%%84$'9&#'&3@)&"*.7'5"4'#&')964+#)&9>'`$%+&#)+*'$95'$9#)+8&.)94%A)+':45)+$#)&9*'*"+8'$*'87&*+)94'3"#7.3%&:)54'+$9'84.-'%45"+4'5)$%%84$')6'.&-4%$:)54')*'9&#'$@$).$3.4>
TABLE 2.5 Essential Therapies for Treating Constipation
Treatment Dose
Glycerin suppository Adult: 4 gm suppository per rectum dailyChild ( 40 kg): 2 gm suppository per rectum daily
Lactulose syrup Adult: 15–45 ml 2–3 times per day orally, maintain 30–90 ml/dayChild ( 40 kg): 7.5 ml 1 time per day orally
Bisacodyl Adult: 10 mg once or twice daily, orally or per rectumChild ( 40 kg): 0.3 mg/kg once daily by mouth. Maximum dose: 10 mg. Can also be given per rectum
Naloxone Adult: 1–2 mg every 8 hours. Should only be given orally for this indication
30 chronic care integration for endemic non-communicable diseases
TABLE 2.6 Symptomatic Management of Diarrhea
Treatment Dose
Loperamide Adult: 4 mg orally initially, then 2 mg orally after every loose stool, up to a maximum of 16 mg per dayChild (weight 13–20 kg): 1 mg orally 3 times per dayChild (weight 21–30 kg): 2 mg orally up to 3 times per day
Morphine, liquid preparation (low dose) Adult: 2.5 mg every 8 hours. May give orally, buccally, or rectallyChild ( 40kg): 0.15 mg/kg, up to 2.5 mg every 4 hours. Administer as with adults
Hyoscine butylbromide Adults: 10–20 mg every 6 hours orally or rectally
2.2.8 Delirium/AgitationG$#)49#*'<)#8'#4%:)9$.')..94**':$7'34+&:4'54.)%)&"*'<)#8'&%'<)#8&"#'
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2.2.9 Pruritus and Pressure UlcersG%"%)#"*'&%')#+8)9A')*'$'+&::&9'3"#'&6#49'&@4%.&&P45'*)54'4664+#'&6'+8%&9)+')..94**'#8$#'+$9'+$"*4'*4@4%4'5)*#%4**>';49$.'6$)."%4'&6#49'+$"*4*'-%"%)#"*>'L97'-$#)49#'<)#8'+8%&9)+')..94**')*'$#'%)*P'6&%'+8&.4*#$*)*C'<8)+8'$.*&'+$9'+$"*4')#+8)9A>'b-)$#4*'+$9'$.*&'+$"*4'-%"%)#"*>'
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chapter!2 | palliative care and chronic care 31
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TABLE 2.7 Management of Chronic Pruritus and Skin Care
Condition Treatment
Pruritus due to dry skin, renal failure
Emollient lotion such as calamine
Chlorpheniramine:Adult: 4 mg orally every 4 hours, around the clock or as neededChild ( 40 kg): 1–2 mg orally every 4 hours, around the clock or as needed
Contact dermatitis (e.g., from tape used in hospitals)
Remove allergenic substanceHigh-potency topical steroid such as 0.05% betamethasone valerate
Scabies Permethrin lotion applied from head (avoid face) to toes. Leave lotion on for 8–14 hours, then wash o#. The usual adult dose is 20–30 grams. Repeat in 1 week. Wash all clothes and bedding and dry in the sun. Do not use for babies less than 2 months old
Cholestasis Adult: Prednisolone 10 mg per day. Cimetidine 400 mg twice per day.
Pruritus due to opioids Chlorpheniramine: Adult: 4 mg orally every 4 hours, around the clock or as neededChild ( 40 kg): 1–2 mg orally every 4 hours, around the clock or as needed
Foul odor from wounds Keep wound clean. Crush metronidazole tables and sprinkle onto wound daily
2.2.10 Psychosocial and Spiritual Issues2
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32 chronic care integration for endemic non-communicable diseases
Chapter 2!References
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B' G$..)$#)@4'+$%4'6&%',?\iL?(Y'$95'+$9+4%'-$#)49#*')9'\)4#9$:>'L5@$9+45'#%$)9)9A'+"%%)+".":W'R$**$+8"*4##*'T494%$.',&*-)#$.h'J11g>
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chapter 3Role of Community Health Workers, Family Planning, Mental Health, and Social Services in the Treatment of Chronic Disease
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3.1 Community Health Workers
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34 chronic care integration for endemic non-communicable diseases
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3.2 Housing Assistance
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chapter!3 | community health workers and allied services 35
3.3 Nutritional Support
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3.4 Mental Health
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+&"9*4.&%>
3.5 Family Planning in Chronic Disease
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36 chronic care integration for endemic non-communicable diseases
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chapter!3 | community health workers and allied services 37
Chapter 3!References
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chapter 4Heart Failure
,4$%#'6$)."%4'$++&"9#*'6&%'0m'#&'/1m'&6'8&*-)#$.)^$#)&9*'$:&9A'$5".#*'#8%&"A8&"#'*"32Y$8$%$9'L6%)+$>/2g'Y"%@47*'5$#)9A'3$+P'#&'#84'/d01*'*8&<'#8$#'#84*4'9":34%*'8$@4'9&#'+8$9A45'*"3*#$9#)$..7'6&%'$#'.4$*#'#84'-$*#'8$.62+49#"%7>'?9'#84'/dg1*'$95'/dd1*C'#84')9#%&5"+#)&9'&6'#<&25):49*)&9$.'4+8&+$%5)&A%$-87'84.-45'+.$%)67'#84'+$"*4*'&6'84$%#'6$)."%4')9'#8)*'*4##)9A>d';4-&%#*'6%&:'%464%%$.'+49#4%*'&9'#84'+&9#)949#'*8&<45'#8$#':&*#'+$*4*'&6'84$%#'6$)."%4'<4%4'5"4'#&'9&92)*+84:)+'+$%5)&:7&-$2#8)4*C'+&9A49)#$.'84$%#'5)*4$*4C'%84":$#)+'84$%#'5)*4$*4C'&%'87-4%#49*)@4'84$%#'5)*4$*4'%$#84%'#8$9'+&%&9$%7'$%#4%7'5)*4$*4'V*44'TABLE 4.1X>'U@49')9'"%3$9'+49#4%*'<)#8'$9')9+%4$*)9A'-%4@$.49+4'&6'@$*+".$%'%)*P'6$+#&%*C'9&92)*+84:)+'4#)&.&A)4*'&6'84$%#'6$)."%4'*#)..'5&:)9$#45>/12/g
† Age = Mean Age; * RHD = Rheumatic heart disease; ‡ DCM = Dilated cardiomyopathies; § EMF = Endomyocardial fibrosis; †† HTN HD = Hypertensive heart disease; ‡‡ ICM = Ischemic cardiomyopathy
tt These series reported total valvulopathies. §§ Patients were double counted if they had two etiologic processes.
TABLE 4.1 Causes of Heart Failure Reported by Selected Echocardiographic Referral Centers in Sub-Saharan Africa
Authors Country n Age† RHD. (%) DCM‡ (%) EMF§ (%) HTN HD†† (%) ICM‡‡ (%)
Amoah et al. 200019
Ghana 572 42 115 (20) 65 (11) 22 (4) 122 (21) 56 (10)
Freers et al. 19969
Uganda 406 N/A 58 (12) 40 (8) 99 (22) 38 (8) 4 (1)
Kingue et al. 200520
Cameroon 167 57 41 (25)tt 46 (27) 5 (12) 91 (55) 4 (3)
Thiam et al. 200221
Senegal 170§§ 50 76 (45)tt 12 (7) 0 (0) 58 (34) 30 (18)
?9';<$95$C'<4'8$@4'6&"95'$'*):).$%'5)*#%)3"#)&9'&6'+$"*4*'&6'84$%#'6$).2"%4'$#'%"%$.'5)*#%)+#'8&*-)#$.*'V*44'FIGURE 4.1X>';&"A8.7'8$.6'#84'+$*4*'$%4'-1#)$.'*"%A)+$.'+$95)5$#4*>
Rheumatic heart disease33%
8%
13%
3%
2%
41%Cardiomyopathy
Rheumatic heart diseaseOtherCor pulmonale
CardiomyopathyHypertensive heart diseaseCongenital heart disease
40 chronic care integration for endemic non-communicable diseases
FIGURE 4.1 Distribution of Causes of Heart Failure in a Rwandan NCD clinic (n = 134)
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chapter!4 | heart failure 41
4.1 Defining Categories of Heart Failure
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42 chronic care integration for endemic non-communicable diseases
TABLE 4.2 Important Diagnostic Categories in Heart Failure
1. Cardiomyopathy
Diagnostic criteria 1. Moderately to severely depressed left ventricular function (ejection fraction u 40%)
2. Hypertensive heart disease
Diagnostic criteria 1. Severe hypertension 2. Shortness of breath3. Normal to mildly depressed left ventricular function (ejection fraction 40%)
3. Mitral stenosis
Diagnostic criteria 1. Mitral valve that doesn’t open well with typical hockey-stick or elbow deformity2. Normal to mildly depressed left ventricular function (ejection fraction 40%)
4. Other valvular heart disease (including rheumatic and congenital)
Diagnostic criteria 1. Normal to mildly depressed left ventricular function (ejection fraction 40%)2. No mitral stenosis3. Blood pressure 180/110 mmHg4. Dramatic heart murmur
5. Isolated right heart failure
Diagnostic criteria 1. Ejection fraction 40% 2. No mitral stenosis3. Blood pressure 180/110 mmHg4. No heart murmur5. Large right ventricle or dilated inferior vena cava on echocardiography
4.2 Physical Exam Findings for Classification of Heart Failure
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2*)*>'_4'$.*&'5&'9&#'5<4..'&9'#84'+8$%$+#4%)^$#)&9'&6'#84'#7-4'&%'.&+$#)&9'&6'#84':"%:"%*>
Left ventricle
Right ventricle
Aorticroot
Left atrium
Mitral valve(anterior leaflet)
Mitral valve(posterior leaflet)
chapter!4 | heart failure 43
TABLE 4.3 Physical Exam Findings in Classification of Heart Failure
1. Dramatic murmurs2. Blood pressure 180 mmHg systolic or 110 mmHg diastolic
4.3 Echocardiography for Classification of Heart Failure
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TABLE 4.4 Echocardiographic Findings in Classification of Heart Failure
1. Moderately to severely decreased EF (u 40%)2. Mitral stenosis3. Very large right ventricle (much larger than the aortic root or left atrium)4. Clearly enlarged and non-collapsing vena cava ( 2.5 cm)
4.3.1 The Parasternal Long Axis ViewH84'-$%$*#4%9$.'.&9A'$E)*'@)4<')*'&3#$)945')9'#84'6&..&<)9A':$994%W'<)#8'#84'-$#)49#'.7)9A'&9'#84'.46#'*)54C'#84'-%&34')*'-.$+45'#&'#84'.46#'&6'#84'*#4%9":C')9'#84'K#8'&%'0#8')9#4%+&*#$.'*-$+4C'<)#8'#84'-%&34':$%P4%'-&)9#45'#&<$%5'#84'%)A8#'*8&".54%>'H84':)#%$.'@$.@4'$95'$&%#)+'@$.@4'*8&".5'34'+.4$%.7'*449'V*44'FIGURE 4.2'$95'FIGURE 4.3X>
FIGURE 4.2 Parasternal Long Axis View
Right ventricle
Left ventriclein diastole
Left ventriclein systole
Aorticroot
Leftatrium
Mitral valve
Closed mitral valve
(anterior leaflet)Mitral valve
(posterior leaflet)
44 chronic care integration for endemic non-communicable diseases
FIGURE 4.3 Normal Parasternal Long Axis View on Echocardiography (Diastole, top; Systole, bottom)
4.3.2 The Subcostal ViewH84'*"3+&*#$.'@)4<')*'&3#$)945'<)#8'#84'-%&34'-.$+45'"954%'#84'E)-8&)5'
#84'.)@4%'*449'$#'#84'#&-'&6'#84'*+%449'V*44'FIGURE 4.4X>'H84'?\S')*'*449'$*'$'3.$+P'#"34'49#4%)9A'#84'%)A8#'@49#%)+.4'V*44'FIGURE 4.5X>'?#'*8&".5'34':4$*"%45'J'+:'6%&:')#*'49#%$9+4')9#&'#84'%)A8#'@49#%)+.4>'
Tricuspidvalve
Rightventricle
LeftventricleInferior vena cava (IVC)
Liver
Left atrium
Right atrium
Mitral valve
chapter!4 | heart failure 45
FIGURE 4.4 Subcostal View
Rightventricle
Leftventricle
TricuspidvalveRight atrium
Left atrium
Dilatedinferior
vena cava(IVC)
Liver
Liver
Right atrium
Inferiorvena cava
(IVC)
Mitral valve
46 chronic care integration for endemic non-communicable diseases
FIGURE 4.5 Subcostal View with Normal IVC (top) and Dilated IVC (bottom)
_4'8$@4'6&"95'#8$#'$*'+.)9)+)$9*'34+&:4':&%4'$54-#'$#'#84*4'@)4<*C':$97'#$P4')#'"-&9'#84:*4.@4*'#&'.4$%9'#84'T%'3$*)+'4+8&+$%5)&A%$-82
3"#')*'9&#'4**49#)$.')9'54#4%:)9)9A'$--%&-%)$#4':45)+$.':$9$A4:49#'&6'84$%#'6$)."%4>'[&%':&%4')9254-#8')9*#%"+#)&9'&9'4+8&+$%5)&A%$-87'#4+89)O"4*C'-.4$*4'%464%'#&'#84'<9A+8(4.(/+$D+E/,#(*$.4)+D$#+;'*$.#5'F:2-2,')+=',,24>*>JK
chapter!4 | heart failure 47
4.3.3 Ejection Fraction and Fractional Shortening2
#$9#'5)$A9&*#)+'*P)..')9'+$#4A&%)^)9A'84$%#'6$)."%4>'U['%464%*'#&'#84'$:&"9#'&6'3.&&5'#8$#'#84'84$%#'-":-*'&"#'<)#8'4$+8'34$#>'UD4+#)&9'6%$+#)&9')*'$':4$*"%4'&6'#84'84$%#=*'*7*#&.)+'6"9+#)&9W'8&<'<4..'#84'84$%#'<&%P*'5"%)9A'#84'*O"44^)9A'-8$*4'&6'#84'+$%5)$+'+7+.4>'L'9&%:$.'U[')*'34#<449'00m'$95'Z0mC':4$9)9A'#8$#'#84'9&%:$.'84$%#'-":-*'$3&"#'8$.6'&6'#84'3.&&5')9'#84'.46#'@49#%)+.4'&"#')9#&'#84'$&%#$'<)#8'4$+8'34$#>
00mXC'$95':&54%$#4.7'#&'*4@4%4.7'%45"+45'Vu'K1mX>'L':&54%$#4.7'#&'*4@4%4.7'%45"+45'U[':4$9*'$'-$#)49#'8$*'$'+$%5)&:7&-$#87C'$'6$)."%4'&6'#84'84$%#':"*+.4>'_8).4'4+8&+$%5)&A%$-87':$+8)94*'+$9'A494%$#4':4$*"%4:49#*'&6'U[C'O"$.)#$#)@4'@)*"$.'$**4**:49#')*':&%4'%4.)$3.4>'?9'$'+%&**2*4+#)&9$.'@)4<C'#8)*'#%$9*.$#4*')9#&'8&<':"+8'#84'<$..*'&6'#84'@49#%)+.4'$%4'*449'#&':&@4'#&<$%5'4$+8'T%'<)#8'4$+8'84$%#34$#>'H8)*'5)*#$9+4')*'+$..45'#84'6%$+#)&9$.'*8&%#49)9A>'L'9&%:$.'4D4+#)&9'6%$+#)&9'&6'00m'+&%%4*-&95*'#&'$'6%$+#)&9$.'*8&%#49)9A'&6'$3&"#'J0m>'H8)*':4$9*'#8$#'<849'#84'9&%:$.'84$%#'*O"44^4*')9'*7*#&.4C'#84'5)*#$9+4'34#<449'#84'<$..*'9$%%&<*'37'&9.7'J0m>
_4'#4$+8'&"%'+.)9)+)$9*'#&'4@$."$#4'U[')9'#84'-$%$*#4%9$.'.&9A'@)4<>'?#'+$9'$.*&'34'$**4**45')9'#84'-$%$*#4%9$.'*8&%#'$E)*C'$95'$-)+$.'K2+8$:34%'@)4<*>
FIGURE 4.3'*8&<*'#84'9&%:$.'%4.$#)&9*8)-'34#<449'#84'84$%#')9'5)$*#&.4'V%4.$E$#)&9X'$95'*7*#&.4'V+&9#%$+#)&9X>'`&#)+4'#8$#'#84'@&.":4'&6'#84'.46#'@49#%)+.4'54+%4$*4*')9'*7*#&.4C'$95'#84'.46#'@49#%)+".$%'<$..*'34+&:4'#8)+P4%'$*'#84'@49#%)+.4'+&9#%$+#*'$95'*O"44^4*'#84'3.&&5'&"#')9#&'#84'$&%#$>
FIGURE 4.6'*8&<*'8&<'#84'.46#'@49#%)+".$%'<$..*'5&'9&#':&@4'#&A4#84%'@4%7':"+8')9'$'84$%#'<)#8'$'+$%5)&:7&-$#87o#84'.46#'@49#%)+.4'%4:$)9*'$3&"#'#84'*$:4'*)^4'+&9#%$+#45'$*'%4.$E45C'$95'#84'<$..*'5&'9&#'#8)+P49':"+8>'S&:-$%4'#8)*'#&'#84'9&%:$.'84$%#')9'FIGURE 4.3>
Right ventricle
Leftatrium
Left ventriclein diastole
Left ventriclein systole
Aorticroot
Mitral valve
Closed mitral valve
(posterior leaflet)
Mitral valve(anterior leaflet)
48 chronic care integration for endemic non-communicable diseases
FIGURE 4.6 Cardiomyopathy in Parasternal Long Axis View (Diastole, top; Systole, bottom)
4.3.4 Assessment for Mitral Stenosis?9'-$#)49#*'<)#8'%84":$#)+':)#%$.'*#49&*)*C'#84':)#%$.'@$.@4'8$*'$'*#%)P2)9A.7'+8$%$+#4%)*#)+'$--4$%$9+4')9'#84'-$%$*#4%9$.'.&9A'$E)*'@)4<'V*44'FIGURE 4.7X>'H84'64$#"%4*'&6'#7-)+$.'%84":$#)+':)#%$.'*#49&*)*')9+."54W'V/X'$'*:$..'&-49)9A'&6'#84':)#%$.'@$.@4')9'5)$*#&.4'V*44'FIGURE 4.3'$95'FIGURE 4.68$*'$'8&+P47'*#)+P'&%'4.3&<'546&%:)#7h'VBX'.46#'@49#%)+".$%'6"9+#)&9')*'#7-)+$..7'9&%:$.>'
Right ventricle
Leftatrium
Left ventriclein diastole Aortic
root
Mitral valve(anterior leaflet
with hockey stick or elbow deformity)Small opening
of stenotic mitral valve in diastole
Right ventricle(very dilated in diastole)
chapter!4 | heart failure 49
FIGURE 4.7 Mitral Stenosis in Diastole
4.3.5 Assessment of Right Heart Size?9'+$*4*'&6'%)A8#'84$%#'6$)."%4C'#84'%)A8#'@49#%)+.4':$7'$--4$%'49.$%A45'&9'#84'-$%$*#4%9$.'.&9A'$E)*'@)4<'V*44'FIGURE 4.8X>'`&%:$..7C'#84'%)A8#'@49#%)+.4')*'%&"A8.7'#84'*$:4'*)^4'$*'#84'$&%#)+'%&&#'$95'#84'.46#'$#%)":>'
FIGURE 4.8 Right Ventricular Enlargement (Parasternal Long View)
50 chronic care integration for endemic non-communicable diseases
4.3.6 Assessment of the Inferior Vena CavaH84')964%)&%'@49$'+$@$')9'#84'*"3+&*#$.'@)4<'*8&".5'34'*:$..'$95'+&.2.$-*4'6"..7'<)#8'4$+8')9*-)%$#)&9>'L9'?\S'A%4$#4%'#8$9'J'+:'#8$#'5&4*9=#'+&..$-*4')*'*#%&9A.7'*"AA4*#)@4'&6'*&:4'4.4:49#'&6'%)A8#2*)545'84$%#'6$)."%4'V*44'FIGURE 4.5X>'
4.3.7 Assessment of Pericardial E!usion G4%)+$%5)$.'466"*)&9*'+$9'&++"%')9':$97'5)664%49#'#7-4*'&6'84$%#'6$)."%4>'H847'+$9'$.*&'&++"%')9'-$#)49#*'<)#8'9&'8)*#&%7'&6'84$%#'6$)."%4C'*"+8'$*'#8&*4'<)#8'+$9+4%'&%'%49$.'6$)."%4>'H847'$%4'.)*#45'84%4'$*'$'P47'4+8&+$%2
2
*8&".5'-%&:-#')::45)$#4'$5:)**)&9'#&'#84'5)*#%)+#'8&*-)#$.'6&%'-&**)3.4'
5)$A9&*#)+'+%)#4%)$'6&%'84$%#'6$)."%4'+$#4A&%)^$#)&9>'
*"3+&*#$.'@)4<C'3"#'+$9'$.*&'34'*449')9'#84'-$%$*#4%9$.'.&9A'$E)*'@)4<'V*44'FIGURE 4.9X>'R$97'-$#)49#*':$7'8$@4'*:$..'-4%)+$%5)$.'466"*)&9*>
Large pericardiale!usion
Large pericardiale!usion
Left ventricle
Left atrium
Liver
chapter!4 | heart failure 51
FIGURE 4.9 Pericardial E"usion (Parasternal View, top; Subcostal View, bottom)
4.4 Initial Recognition and Referral of the Heart Failure Patient
,4$%#'6$)."%4'-$#)49#*':$7'-%4*49#'#&'$97'.4@4.'&6'#84'84$.#8'+$%4'*7*#4:>'
34'%464%%45'#&'#84'5)*#%)+#'`S('+.)9)+>
L#'84$.#82+49#4%'[email protected]'84$%#'6$)."%4'-$#)49#*'&6#49'-%4*49#'<)#8'9&92
+.)9)+$..7'):-&%#$9#'84$%#'6$)."%4')9';<$95$'<)..'8$@4'*8&%#94**'&6'3%4$#8'$#'$'54+%4$*45'.4@4.'&6'$+#)@)#7>'S.)9)+)$9*'*8&".5'%464%'-$#)49#*''#&'#84'`S('+.)9)+'<8&'5&'9&#'8$@4'$9')964+#)&"*'-%&+4**'#&'4E-.$)9'#84)%'
52 chronic care integration for endemic non-communicable diseases
TABLE 4.5'V*44'34.&<X'#&'*"AA4*#'$9'"954%.7)9A'+$%5)$+'4#)&.&A7>'CHAPTER 102&"#.)94*'#84'$+"#4'+$%4'84$.#8'+49#4%'$--%&$+8'#&'*8&%#94**'&6'3%4$#8>
TABLE 4.5 Common Signs and Symptoms of Heart Failure (Usually Present in Addition to Shortness of Breath)
1. Lower-extremity edema2. Loud murmurs3. Orthopnea (shortness of breath when lying prone)
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L9T%'A%&"-'&6'84$%#'6$)."%4'-$#)49#*'<)..'34'%464%%45'6%&:'#84'5)*#%)+#'8&*-)#$.')9-$#)49#'"9)#*>'R$97'-$#)49#*'<)#8'84$%#'6$)."%4'&9.7'*44P':45)+$.'+$%4'&9+4'#847'8$@4'34+&:4'@4%7')..'$95'%4O")%4'8&*-)#$.)^$#)&9>'L.A&%)#8:*'6&%'%4+&A9)#)&9'$95':$9$A4:49#'&6'84$%#'6$)."%4'-$#)49#*')9'#84')9-$#)49#'5)*#%)+#'8&*-)#$.'$%4')9+."545')9'#84'_,b=*'6&%#8+&:2)9A'5)*#%)+#'+.)9)+)$9':$9"$.'6&%'$5".#'$95'$5&.4*+49#'+$%4>'H84'_,b'$.A&%)#8:*'$%4'*):).$%'#&'#8&*4'-%4*49#45'84%4'6&%'"*4')9'#84'&"#-$#)49#'*4##)9AC'<)#8'$9'$5545'4:-8$*)*'&9'*#$3).)^$#)&9'&6'#84'*4@4%4.7'54+&:2-49*$#45'-$#)49#>'G$#)49#*'$%4'*#$%#45'&9'$--%&-%)$#4'&"#-$#)49#'#84%$-7'-%)&%'#&'5)*+8$%A4'$95'A)@49'$'6&..&<2"-'$--&)9#:49#')9'#84'5)*#%)+#2.4@24.'`S('+.)9)+>'?9'*&:4'+$*4*C'#84'`S('+.)9)+'9"%*4*':$7'*44'8&*-)#$.)^45'84$%#'6$)."%4'-$#)49#*'#&A4#84%'<)#8'#84)%'-87*)+)$9*'#&'84.-'49*"%4'A&&5'+&9#)9")#7'&6'+$%4>
Y"*-4+#45'84$%#'6$)."%4'-$#)49#*'%464%%45'#&'#84'5)*#%)+#'`S('+.)9)+'*8&".5'%4+4)@4'$'+&:-.4#4'8)*#&%7C'-87*)+$.'4E$:C'$95'4+8&+$%5)&A%$-87>'
2%)4*'&%'%4+4)@4'$9'$.#4%9$#4C'9&92+$%5)$+'5)$A9&*)*>
S.)9)+)$9*'<)..'#849'54#4%:)94'#84')9)#)$.'#%4$#:49#'3$*45'&9'#84'#%4$#2:49#'$.A&%)#8:'6&%'#8$#'5)$A9&*#)+'+$#4A&%7'V*44'PROTOCOL 4.1X>
chapter!4 | heart failure 53
34'%464%%45'6&%'$5:)**)&9'#&'#84'5)*#%)+#'8&*-)#$.'6&%'*#$3).)^$#)&9'$95'5)"%4*)*'V*44'PROTOCOL 4.2X>'
G$#)49#*'$%4'#849'$**4**45'6&%'#84'-%4*49+4'&%'$3*49+4'&6'$'+$%5)&:72
$*'8$@)9A'$'+$%5)&:7&-$#87>';4A$%5.4**'&6'T%'$39&%:$.)#)4*C'#84*4'-$#)49#*'<)..'34'#%4$#45'$++&%5)9A'#&'#84'+$%5)&:7&-$#87'#%4$#:49#'A")54.)94*'V*44'SECTION 4.8X>
b9+4'+$%5)&:7&-$#87'8$*'3449'%".45'&"#C'-$#)49#*'$%4'$**4**45'6&%'#84'-%4*49+4'&6':)#%$.'*#49&*)*'&9'4+8&+$%5)&A%$-87>'H84*4'-$#)49#*'$%4'#%4$#45'$*'8$@)9A':)#%$.'*#49&*)*C'%4A$%5.4**'&6'#84'-%4*49+4'&6'T%'@$.@".$%'.4*)&9*'V*44'SECTION 4.10X>
G$#)49#*'<)#8&"#'+$%5)&:7&-$#87'&%':)#%$.'*#49&*)*'$%4'#849'$**4**45'6&%'-%4*49+4'&6'*4@4%4'87-4%#49*)&9>'?6'-%4*49#C'#847'$%4'+$#4A&%)^45'$*'8$@)9A'87-4%#49*)@4'84$%#'5)*4$*4'V*44'SECTION 4.9X>
;4:$)9)9A'-$#)49#*'$%4'#849'$**4**45'6&%'-%4*49+4'&6'$'84$%#':"%:"%>'H8&*4'<)#8'.&"5C'&3@)&"*':"%:"%*'<)#8&"#'+$%5)&:7&-$#87C':)#%$.'*#49&*)*C'&%'87-4%#49*)@4'84$%#'5)*4$*4'$%4'+$#4A&%)^45'$*'8$@)9A'*&:4'@$%)4#7'&6'+&9A49)#$.'&%'%84":$#)+'@$.@".$%'5)*4$*4'$-$%#'6%&:':)#%$.'*#49&*)*'V*44'SECTION 4.11X>
H84'%4:$)9)9A'-$#)49#*'$%4'4@$."$#45'6&%'*)A9*'&6')*&.$#45'%)A8#'84$%#'6$)."%4C'*"+8'$*'$'@4%7'.$%A4'%)A8#'@49#%)+.4'&%'$'5).$#45'?\S'&9'4+8&+$%2
6$)."%4'V*44'SECTION 4.12X>
9&92+$%5)$+'+$"*4*'&6'#84)%'*7:-#&:*C'*"+8'$*'%49$.'&%'.)@4%'6$)."%4>
YES
NO
NO
NOYES
YES
YES
YES
NO
NO
NO
NO
YES YES
NO
YES
NO
YES
Consider alternate diagnoses
Suspected or confirmed heart failure
Signs ofdecompensated
heart failure?(Table 4.7)
Echo-confirmedheart disease?(Section 4.3)
Ultrasound available?
Abnormal left ventricular
function?
Murmur
BP ≥ 180/110 mmHg
Treat as valvular/ congenital disease
(Protocol 4.12)
Mitral stenosis?
Treat as mitralstenosis
(Protocol 4.11)
Treat ascardiomyopathy(Protocol 4.4)
Follow appropriate treatment protocol
according todiagnosis
(Protocols 4.3–4.18)
Treat as decompensated
heart failure (Protocol 4.2)
Treat as hypertensiveheart disease
(Protocol 4.8) Signsof right-
sided heartfailure
Large, non-collapsing
IVC or very large right ventricle
Treat as right-sided heart failure
(Protocol 4.15)
54 chronic care integration for endemic non-communicable diseases
PROTOCOL 4.1 Initial Diagnosis and Management of Heart Failure
`4E#C'$..'#%4$#:49#'$.A&%)#8:*'34A)9'<)#8'$9'$**4**:49#'&6'#84'-$#)49#=*'*7:-#&:'*4@4%)#7'$95'@&.":4'*#$#"*>'H8)*'$**4**:49#'<)..'34'5)*+"**45')9'#84'6&..&<)9A'*4+#)&9*>
chapter!4 | heart failure 55
4.5 Heart Failure Severity Classification
G$#)49#*'<)#8'84$%#'6$)."%4'&6'$97'4#)&.&A7'6$..'$.&9A'$'+&::&9'+&9#)9"2":'&6'*7:-#&:'*4@4%)#7>'H84*4'$%4'+$#4A&%)^45')9#&'6&"%'A%&"-*C'3$*45'
TABLE 4.6X>'
+.4$%.7'5&+":49#'$'84$%#'6$)."%4'-$#)49#=*'+.)9)+$.'+&"%*4>
R).5'$39&%:$.)#)4*'&6'84$%#'*#%"+#"%4*')9':$97'+$*4*'94@4%'.4$5'#&'*7:-#&:*'&6'84$%#'6$)."%4>'G$#)49#*'<)#8':&54%$#4'#&'*4@4%4'$39&%:$.)2#)4*':$7'$.*&'34'$*7:-#&:$#)+'&%':).5.7'*7:-#&:$#)+'V+.$**'?'&%'??X'6&%':&9#8*'#&'74$%*C'#8$9P*'#&'#84'3&57=*'+&:-49*$#&%7':4+8$9)*:*>',&<4@4%C'$*'84$%#'6$)."%4'-%&A%4**4*C'#84*4'+&:-49*$#&%7':4+8$9)*:*'A494%$..7'6$).'$95'-$#)49#*'54@4.&-':&%4'*7:-#&:*C'-.$+)9A'#84:')9'$'8)A84%'84$%#'6$)."%4'+.$**>',4$%#'6$)."%4'#%4$#:49#'+$9'*.&<'$95'*&:42#):4*'4@49'%4@4%*4'#8)*'-%&A%4**)&9C'$..&<)9A'*&:4'-$#)49#*'#&':&@4'#&'$'.&<4%'84$%#'6$)."%4'+.$**>
TABLE 4.6 New York Heart Association Heart Failure Classification
Class I Patients with cardiac disease but no resulting limitation of physical activity. Ordinary physical activity does not cause symptoms.
Class II Patients with cardiac disease resulting in mild limitation of physical activity. Patients are comfortable at rest. Ordinary physical activity (farming, running, carrying water, climbing a hill) causes symptoms.
Class III Patients with cardiac disease resulting in moderate limitation of physical activity. Patients are comfortable at rest. Less than ordinary physical activity (light housework, walking on flat ground) causes symptoms.
Class IV Patients with cardiac disease resulting in severe limitation of physical activity. Patients have symptoms at rest. Any physical activity causes symptoms.
4.6 Decompensated Heart Failure
_849'$'-$#)49#=*'3&57')*'9&'.&9A4%'+&:-49*$#)9A'<4..'6&%'#84'54A%44'&6'84$%#'57*6"9+#)&9C'@&.":4'*#$#"*'$95'6"9+#)&9$.'$3).)#7'<)..'<&%*49>'H8)*')*'#4%:45'54+&:-49*$#45'84$%#'6$)."%4>'S."4*'#8$#'$'-$#)49#'8$*'49#4%45'#8)*'*#$#4'$%4'$39&%:$.'@)#$.'*)A9*'V*"+8'$*'.&<'3.&&5'-%4**"%4'$95'6$*#'84$%#'%$#4X'$95'*4@4%4'*7:-#&:*'&6'57*-94$'$95'&%#8&-94$'V*44'TABLE 4.7X>'H84*4'-$#)49#*'$%4'#&&'*)+P'#&'34'#%4$#45')9'#84'+&::"9)#7'$95'
PROTOCOL 4.2'-%&@)54*'A")5$9+4'&9'8&<'#&'4@$."$#4'$95')9)#)$#4'#%4$#2:49#'6&%'-$#)49#*'<)#8'54+&:-49*$#45'84$%#'6$)."%4>
56 chronic care integration for endemic non-communicable diseases
TABLE 4.7 Signs of Decompensated Heart Failure in Adults
Vital signs Blood pressure Very low (SBP 80 mmHg)Very high (SBP 180 mmHg)
Pulse Very low ( 40 bpm)Very high ( 120 bpm)
High respiratory rate 24 breaths/minute
Low oxygen saturation Saturation 90%
Symptoms Inability to lie down flatSevere dyspnea at rest
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H84'6&..&<)9A'@)#$.'*)A9*'*8&".5'34'+&..4+#45'&9'4@4%7'@)*)#W'84$%#'%$#4C'3.&&5'-%4**"%4C'$95'<4)A8#>'bE7A49'*$#"%$#)&9C'%4*-)%$#&%7'%$#4C'$95'#4:-4%$#"%4'*8&".5'34'+84+P45')6'$'-$#)49#'*44:*')..'&%')9'5)*#%4**>
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TABLE 4.8'.)*#*'*&:4'&6'#84'+&::&9'%4$*&9*'6&%'$+"#4'<&%*49)9A'&6'$'
+$9'%4*".#')9'*4@4%4'54+&:-49*$#)&9'&6'#84'84$%#'6$)."%4'-$#)49#>'L+"#4')9+%4$*4*')9'3.&&5'-%4**"%4':$7'+$"*4'#84'84$%#'#&'*#)6649'$95'$'*"32
454:$>',4$%#'6$)."%4'-$#)49#*'<)#8'*)A9*'&6'54+&:-49*$#)&9'$95'@4%7'8)A8'3.&&5'-%4**"%4*'*8&".5'%4+4)@4')::45)$#4')9#4%@49#)&9*'#&'.&<4%'3.&&5'-%4**"%4'V*44'SECTION 8.4'$95'TABLE 8.4X>
F$%A4'+8$9A4*')9'@)#$.'*)A9*'&%'@4%7'$39&%:$.'@$."4*'*8&".5'#%)AA4%'V/X')9@4*#)A$#)&9'&6'#84'+$"*4h'VJX')9)#)$.'$##4:-#*'#&'*#$3).)^4'#84'-$#)49#h'$95'VBX'-%4-$%$#)&9*'6&%'#%$9*64%'#&'$'8)A84%'.4@4.'&6'+$%4>'Y44'PROTOCOL 4.2'6&%'#84'$.A&%)#8:'6&%')9)#)$.':$9$A4:49#'&6'54+&:-49*$#45'84$%#'6$)."%4>
chapter!4 | heart failure 57
TABLE 4.8 Reasons for Acute Decompensation in Patients with Heart Failure
1. Medication nonadherence or recent changes in medications
2. Change in diet (e.g., increase in salt intake)
3. Acute illness (e.g., pneumonia, rheumatic fever, endocarditis)
5. Worsening valvular disease
6. PregnancyExacerbates all types of heart failure, but especially mitral stenosis (2nd and 3rd trimester) and peripartum cardiomyopathy.
7. ArrhythmiaEspecially common in patients with cardiomyopathies and valvular disease, particularly mitral stenosis.
8. Worsened hypertensionVery high blood pressure can cause acute sti#ening of the heart muscle and back up of fluid into the lungs (pulmonary edema).
NO
NO
NO
YES
NO
YES
NO
YES
NO
YES
YES
Check creatinine,consider
alternative diagnosis
Initial furosemide dose (Table 4.10)
Diuresis within 30 minutes?
Dose escalation
(Table 4.10)
Diuresis after 1–2 dose
escalations?
Look for other reasons for
decompensation and treat accordingly
Lower blood pressure
(see Table 8.4, Section 8.4)
Signs of Decompensated Heart Failure(Table 4.7)
Place IV, hospitalize or prepare for transfer to
hospital
Signs of fluid overload
(Table 4.9)
Treat according to diagnosis
(Sections 4.8–4.12)
BP ≥ 180/110 mmHg?
HR ≥ 120 Obtain ECG
Signs of atrial fibrillation (irregularly spaced QRS and/or
no P waves)
Load withdigoxin, start
anticoagulation(see Section 4.16.1)
58 chronic care integration for endemic non-communicable diseases
PROTOCOL 4.2 Management of Decompensated Heart Failure
4.7 Fluid Status Assessment
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2
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chapter!4 | heart failure 59
_)#8'-%$+#)+4C'+.)9)+)$9*'*8&".5'34'$3.4'#&':$P4'$'%4$*&9$3.4'$**4**2
#8)*'$**4**:49#'<%&9A>',4%4'$*')9':&*#'&6':45)+)94C')6'$'#84%$-7'5&4*'9&#'-%&5"+4'#84'4E-4+#45'%4*".#C'#84'5)$A9&*)*'*8&".5'34'%4+&9*)54%45>
,4$%#'6$)."%4'-$#)49#*'<)..'6$..')9#&'#8%44'3%&$5'@&.":4'*#$#"*'+$#4A&%)4*W'
:"+8'9&%'#&&'.)##.4X'$95')*'$#'$'5%7'<4)A8#h'&%'VBX'87-4%@&.4:)+C':4$9)9A'
_)#8)9'#84'87-4%@&.4:)+'+$#4A&%7C'#84%4'$%4'#8%44'*"3+$#4A&%)4*'3$*45'
&6'+"%%49#'<4)A8#'#&'#84'-$#)49#=*'5%7'<4)A8#C')6'P9&<9>
:$P)9A'*-4+)$.'9'&6'<84#84%'#84'94+P'@4)9*'$%4'5)*#49545C'<84#84%'#84%4'$%4'+%$+P.4*'&9'."9A'4E$:C'$95'<84#84%'#84%4')*'$97'.&<4%24E#%4:)#7'454:$'&%'$*+)#4*>
TABLE 4.9 Volume Status Categories and Diuretic Adjustment
Category Hypovolemic Euvolemic Hypervolemic
Mild Moderate Severe (decompensated)
Weight Less than dry weight
At dry weight 5 kg above dry weight
5 kg above dry weight
5 kg above dry weight
Symptoms Variable Class I–II Class I–II Class II–III Class III–IV
Vital signs TachycardiaHypotension
Normal Normal Mild tachycardia Tachycardia, tachypnea, hypoxia, hypotension, or hypertension
Physical exam
Does not always correlate with severity. Signs of fluid overload include distended neck veins, lung crackles, louder murmurs, hepatomegaly, ascites, and lower-extremity edema. However, can be intravascularly hypovolemic and still have signs of hypervolemia in lungs, extremities, and abdomen.
Creatinine Increased Stable or decreased
Stable or decreased
Can be increased (due to hypoperfusion of the kidneys), stable or decreased.
Diuretic adjustment
Stop all diuretics
Reduce or maintain dose (if starting beta-blocker, do not reduce diuretic)
Maintain or increase dose
Increase dose or add second agent
Start IV furosemide and prepare for transfer to hospital if possible
Hypovolemia
Decrease ORmaintain
diuretic dose
Stop alldiuretics,consider
giving fluids
Perform volume assessment
Mild
Hypervolemia
Moderate Severe
Low EFAND
starting orincreasing
beta-blockerdose
Maintain OR
increase diuretic
dose
Increase diuretic
dose
IV diuresis,hospitalize
Euvolemia
Maintaindiuretic
dose
Suspected or confirmed heart failure
NOYES
60 chronic care integration for endemic non-communicable diseases
V*44'TABLE 4.9%)A8#2*)545'6$)."%4C'&%'%49$.'6$)."%4':$7'+&9#)9"4'#&'8$@4'%4*)5"$.'454:$'54*-)#4')9#%$@$*+".$%'4"@&.4:)$>'L*'$'-$#)49#'A4#*'+.&*4'#&'8)*'5%7'<4)A8#C'#84'+%4$#)9)94':$7'*#$%#'#&'%)*4>'H8)*')*'&94'*)A9'#8$#')#':$7'34'#):4'#&'54+%4$*4'$'-$#)49#=*'5)"%4#)+'5&*4>
2*)&9')*'<84#84%'#84'-$#)49#'%4O")%4*'8&*-)#$.)^$#)&9'6&%'6$*#C')9#%$@49&"*'
5)"%4*)*'$*'$9'&"#-$#)49#>'L'-$#)49#'<8&'$--4$%*'54+&:-49*$#45'5"4'''
PROTOCOL 4.3'-%4*49#*'$9'$.A&%)#8:'6&%'$--%&-%)$#4':$9$A4:49#'&6'
PROTOCOL 4.3 Volume Status Assessment and Diuretic Adjustment
chapter!4 | heart failure 61
29)94'A%4$#4%'#8$9'J11'n:&.iFX'-&*4'$'*-4+)$.'+8$..49A4'6&%'5)"%4#)+'
):-%&@4'#84'84$%#=*'$3).)#7'#&'-":-'$95')9+%4$*4'#84'$:&"9#'&6'3.&&5'54.)@4%45'#&'#84'P)5947*>';49$.'6"9+#)&9'<)..'):-%&@4C'<)#8'$'%4*".#)9A'
$95'%49$.'6"9+#)&9'<)..'54+.)94C'<)#8'$'%4*".#)9A'%)*4')9'+%4$#)9)94'.4@4.*>'H84%46&%4C')#')*'):-&%#$9#'#&'-$7'$##49#)&9'#&'#84'#%495')9'+%4$#)9)94'$*'$'+."4'#&'#84'-$#)49#=*'+"%%49#'@&.":4'*#$#"*>
&"#*)54'&6'#84'3.&&5'@4**4.*'$95')9'#84'#)**"4*C'$'-$#)49#'+$9'8$@4'#&&'
)9'#84'3.&&5>'H8)*'*)#"$#)&9'<)..'$.*&'.4$5'#&')9+%4$*45'+%4$#)9)94>'[&%'#8)*'%4$*&9C'<4'A494%$..7'%4+&::495'#8$#'+.)9)+)$9*'4%%'&9'#84'*)54'&6'P44-2
4.7.1 Guidelines for Initiating Intravenous DiuresisL..'-$#)49#*'<8&'$%4'54+&:-49*$#45'<)#8'$97'*)A9*'&6'87-4%@&.4:)$'<)..'%4O")%4')9#%$@49&"*'5)"%4*)*>'L*'#84'3&57'34+&:4*')9+%4$*)9A.7'
<8)+8'+$9'.4$5'#&'-&&%'$3*&%-#)&9'&6'&%$.':45)+$#)&9*>'[&%'#8)*'%4$*&9C')9#%$@49&"*'6"%&*4:)54')*'#84'-%464%%45':45)+$#)&9'6&%'-$#)49#*'<)#8'
?9#%$@49&"*'5)"%4*)*'*8&".5'34')9)#)$#45')::45)$#4.7'"-&9'5)$A9&*)*'
["%&*4:)54'*8&".5'<&%P'O")+P.7C'<)#8'$9'$@4%$A4'&9*4#'&6'/0':)9"#4*'6%&:'$5:)9)*#%$#)&9>'?6'#84'-$#)49#'5&4*'9&#'%4*-&95C')#':$7'34'#8$#'#84'#8%4*8&.5'6&%'5)"%4*)*'8$*'9&#'3449'%4$+845'$95'$'8)A84%'5&*4')*'944545>'
5&*4'+$9'34'5&"3.45>'TABLE 4.10'-%&@)54*'*"AA4*#45'*#$%#)9AC'4*+$.$#)&9C'$95':$E):":'5&*4*'&6')9#%$@49&"*'6"%&*4:)54>'["%&*4:)54'.$*#*'$3&"#'Z'8&"%*'$95'*8&".5'34'5&*45'JkB'#):4*'-4%'5$7>
TABLE 4.10 Intravenous Furosemide (Lasix) Dosing
Initial dosing Escalation Maximum dose
Patient does not already take furosemide
Adult:40 mg IV 2x–3x/day
Double every 30 minutes until response or maximum dose achieved
Adult:100 mg IV 2–3x/day
Pediatric ( 40 kg):0.5 mg/kg IV 2x/day
Pediatric:2 mg/kg 2–3x/day
Patient already takes furosemide
Double e#ective outpatient dose and give as IV
62 chronic care integration for endemic non-communicable diseases
["%&*4:)54')*'#<)+4'$*'4664+#)@4'<849'A)@49')9#%$@49&"*.7'$*'<849'A)@49'&%$..7>'?#')*'):-&%#$9#'#&'P44-'#8)*')9':)95'<849'#%$9*)#)&9)9A'-$#)49#*'6%&:'&94'6&%:'&6'#84'5%"A'#&'$9T%'V*44'TABLE 4.11X>
TABLE 4.11 Equivalent Oral and IV Furosemide (Lasix) Doses
Oral IV
80 mg PO 40 mg IV
b9+4'$'-$#)49#'8$*'3449'5)"%4*45'4664+#)@4.7C')#')*'@4%7'):-&%#$9#'#&':$P4'9'&6'#84)%'5%7'<4)A8#o#84'<4)A8#'$#'<8)+8'#84'-$#)49#')*'4"@&.4:)+>'
%4$*&9'#&'34.)4@4'#8$#'#84'-$#)49#'8$*'T%'%4$*&9*'#&'A$)9'<4)A8#'V)>4>C'$'A%&<)9A'+8).5X>'_849'$'-$#)49#')*'5)*+8$%A45'6%&:'#84'8&*-)#$.C'#8)*'@$."4'*8&".5'34'+&::"9)+$#45'#&'#84'&"#-$#)49#'-%&@)54%>
4.7.2 Guidelines for Initiating and Titrating Oral Furosemide at Health-Center Level
R&*#'-$#)49#*'<)#8'84$%#'6$)."%4'<)..'8$@4'$'#49549+7'#&'*#&%4'#&&':"+8'
<)#8'-%&-4%'#84%$-7C'3"#':&*#'<)..'%4O")%4'$'.&<'.&9A2#4%:':$)9#49$9+4'5&*4>'H8)*':4$9*'#8$#'-$#)49#*'<8&'<4%4'-%4@)&"*.7'87-4%@&.4:)+'3"#'34+&:4'4"@&.4:)+'$6#4%'5)"%4*)*'<)..'*#)..'&6#49'%4O")%4'5)"%4#)+*'#&'
3$.$9+4'$95'#&'+&9#%&.'*7:-#&:*>'TABLE 4.12'&"#.)94*'#84'%4+&::49545'5&*)9A'&6'&%$.'6"%&*4:)54>
TABLE 4.12 Oral Furosemide (Lasix) Dosing
Initial dose Dose adjustment Maximum dose
Hypovolemia Euvolemia Mild hypervolemia
Moderate hypervolemia
Severe hypervolemia
Adult: 40 mg 1x/day
Stop all diuretics, consider giving fluid
May attempt to decrease dose unless starting or increasing beta-blocker
Keep dose the same
Double current dose or add second agent
Admission and intravenous diuresis (see TABLE 4.10)
Adult: 80 mg 2x/day
Pediatric:1 mg/kg 1x/day
Pediatric: 2 mg/kg 2–3x/day
4.7.3 Guidelines for Use of Other Diureticsb#84%'&%$.'5)"%4#)+*'34*)54*'6"%&*4:)54':$7'34'"*45'#&'84.-'$+8)4@4'$95':$)9#$)9'4"@&.4:)$'V*44'TABLE 4.13X>'H84*4':45)+$#)&9*'$%4'A494%$..7'$5545'#&'6"%&*4:)54'#&')9+%4$*4'#84'*#%49A#8'&6'5)"%4*)*>'_8).4'#847':$7'34'@4%7'4664+#)@4C'#84*4':45)+$#)&9*'+$9'$.*&')9+%4$*4'#84'+8$9+4*'&6'4.4+#%&.7#4'$39&%:$.)#)4*'$95'T%'*)54'4664+#*'&6'6"%&*4:)54C'$95'*8&".5'34'"*45'<)#8'+$"#)&9>
chapter!4 | heart failure 63
4.7.3.1 SpironolactoneY-)%&9&.$+#&94'V#%$54'9$:4'L.5$+#&94XC'.)P4'6"%&*4:)54C'$+#*'&9'#84'P)5947*'#&')9+%4$*4'"%)9$#)&9>'_8).4'6"%&*4:)54'#495*'#&'+$"*4'87-&P$2.4:)$C'*-)%&9&.$+#&94'<)..':$)9#$)9'&%')9+%4$*4'3.&&5'-&#$**)":'.4@4.*>'Y-)%&9&.$+#&94'+$9'34'-$%#)+".$%.7'4664+#)@4')9'-$#)49#*'<)#8'$*+)#4*>'!4+$"*4'*-)%&9&.$+#&94'+$9')9+%4$*4'3.&&5'-&#$**)":'.4@4.*C')#'*8&".5'&9.7'34'"*45')9'#84'*4##)9A'&6'9&%:$.'%49$.'6"9+#)&9>
4.7.3.2 Hydrochlorothiazide,75%&+8.&%)$^)54')*'$'<4$P4%'5)"%4#)+'#8$9'6"%&*4:)54C'3"#'$+#*')9':"+8'#84'*$:4'<$7>'_849'#$P49'B1':)9"#4*'-%)&%'#&'6"%&*4:)54C'875%&+8.&%)$^)54'+$9':$P4'6"%&*4:)54'<&%P'34##4%C'+$"*)9A'$'.$%A4%'5)"%4*)*>'L'@4%7'*:$..'9":34%'&6'-$#)49#*'*8&".5'%4O")%4'#8)*>'H8)*'+&:23)9$#)&9'+$9'+$"*4':$**)@4'5)"%4*)*'$95'.&**'&6'@)#$.'4.4+#%&.7#4*C'$95'#84%46&%4'*8&".5'&9.7'34'+&9*)54%45')9'+&9*".#$#)&9'<)#8'$'-87*)+)$9'$95'<)#8'@4%7'+.&*4':&9)#&%)9A'&6'4.4+#%&.7#4*>
TABLE 4.13 Other Oral Diuretic Dosing
Drug Initial dosing Notes Maximum dose
Spironolactone Adult: 25 mg 1x/day Add if patient has significant ascites and normal renal function
50 mg/day
Pediatric ( 40 kg): 2.5 mg/kg 1x/day
3 mg/kg/day
Hydrochlorothiazide Adult: 12.5 mg 1x/day Can be used if furosemide is not available or added to furosemide if greater diuresis is desired.
25 mg/day
Pediatric ( 40 kg): 1 mg/kg/day
12 mg/day
4.7.4 Dangers of Diuresis()"%4#)+*'$%4'-&<4%6".':45)+$#)&9*>'?6'"*45')9'4E+4**C'#847'+$9'+$"*4'4E+4**)@4'<$#4%'.&**'$95'%4*".#)9A'5$:$A4'#&'#84'P)5947*>'H8)*')9'#"%9'+$9'+$"*4'5$9A4%&"*'4.4+#%&.7#4'):3$.$9+4*'$95'4@49'54$#8>
[&%'#8)*'%4$*&9C')#')*'):-&%#$9#'#&'4%%'&9'#84'*)54'&6'"*)9A'*:$..4%'5&*4*'$95'P44-)9A'-$#)49#*'*.)A8#.7'87-4%@&.4:)+>'G$#)49#*':"*#'34'45"+$#45'&9'#84'5$9A4%*'&6'&@4%5)"%4*)*'$95')9*#%"+#45'#&'*#&-'#84)%'5)"%4#)+':45)+$#)&9*')6'#847'54@4.&-'64@4%'&%'5)$%%84$C'<8)+8')9'+&:3)9$#)&9'<)#8':45)+$#)&9*'+$9'.4$5'#&'*4%)&"*'54875%$#)&9>
_849'$55)9A'#<&'5)"%4#)+*'#&A4#84%C'#84'4664+#'&9'4.4+#%&.7#4*')*')9+%4$*45>'S&:3)9$#)&9*'*8&".5'34'"*45'&9.7')9'#84'*4##)9A'&6'9&%:$.'+%4$#)9)94>'?6'-&**)3.4C'*&5)":C'-&#$**)":C'$95'+%4$#)9)94'*8&".5'34':&9)#&%45'$#'%4A".$%')9#4%@$.*')9'#84*4'*)#"$#)&9*>
64 chronic care integration for endemic non-communicable diseases
4.8 Cardiomyopathy
H84'#4%:'+$%5)&:7&-$#87'49+&:-$**4*'*4@4%$.'#7-4*'&6'84$%#'5)*4$*4C'$..'&6'<8)+8'.4$5'#&'$'*):).$%'&"#+&:4'&6'84$%#':"*+.4'57*6"9+#)&9>'H84'+&::&9'64$#"%4'&6'$..'#84*4'5)*4$*4*')*'$'.&<'4D4+#)&9'6%$+#)&9C'"*"$..7'.4**'#8$9'K1m'V6%$+#)&9$.'*8&%#49)9A'.4**'#8$9'J1mX>'
H84%4'$%4':$97'5)664%49#'+$"*4*'&6'+$%5)&:7&-$#87'V*44'TABLE 4.14X>'L*'*#$#45'$3&@4C'*&:4'#7-4*'&6'84$%#'6$)."%4'34A)9'$*'$'+$%5)&:7&-$#87>'b#84%*C'8&<4@4%C'*"+8'$*'@$.@".$%'&%'87-4%#49*)@4'84$%#'5)*4$*4C'+$9'-%&A%4**'#&'$'+$%5)&:7&-$#87'&@4%'#):4>'L97'-$#)49#'<)#8'$9'4D4+#)&9'6%$+#)&9'.4**'#8$9'K1mC'%4A$%5.4**'&6'#84'+$"*4C'*8&".5'34'#%4$#45'-%)2:$%).7'$*'$'+$%5)&:7&-$#87>'S$%5)&:7&-$#8)4*'$664+#'-$#)49#*'&6'4@4%7'$A4'A%&"->
TABLE 4.14 Etiology of Cardiomyopathy in Rwanda
Idiopathic Most of the cases of cardiomyopathy are caused by an unknown process. Many may be due to a previous viral infection.
HIV cardiomyopathy HIV can cause direct cellular damage to heart muscle. ARVs can delay or reverse this process.
Alcohol-related cardiomyopathy
Chronic alcohol use can be toxic to the heart muscle. If the patient stops drinking alcohol, the function may improve with time.
Peripartum Women can develop a cardiomyopathy in the last month of pregnancy and up to six months postpartum. This often improves with appropriate management and avoidance of subsequent pregnancies.
Viral myocarditis Many di#erent viruses can infect the heart muscle and cause dysfunction. This often improves with time, but may be permanent.
Anemia Severe anemia (sometimes due to cancer or poor nutrition) can lead to cardiomyopathy. This can improve when the anemia is treated.
Advanced valvular disease
Most valvular conditions causing abnormal flow of blood within the heart can lead to a cardiomyopathy. This is particularly true with regurgitant lesions. This is not the case for pure mitral stenosis, in which the left ventricle is protected, while the right ventricle ultimately su#ers.
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
Assess fluid status, adjust furosemide(Protocol 4.3, Tables 4.9 and 4.12)
Adjust heart failure beta-blocker(Protocol 4.5)
Assess other medication needs(Protocol 4.7)
Follow-up planning(Section 4.13, Table 4.23)
Ejection fraction ≤ 40%
Assess vital signs, treatdecompensated heart failure
(Protocol 4.2)
Assess renal function and potassium, adjust ACE inhibitor OR hydralazine/isosorbide
(Protocol 4.6)
chapter!4 | heart failure 65
L..'+$%5)&:7&-$#8)4*C'%4A$%5.4**'&6'4#)&.&A7C'$%4':$9$A45'<)#8'5)"%4#)+*'$95'<)#8':45)+$#)&9*C'*"+8'$*'34#$23.&+P4%*'$95'LSU')98)3)#&%*C'<8)+8'8$@4'3449'-%&@49')9'+.)9)+$.'#%)$.*'#&'54+%4$*4'%)*P'&6'54$#8'$95'):-%&@4'*7:-#&:*'&@4%'#84'.&9A'#4%:>'PROTOCOL 4.4'-%&@)54*'$9'&"#.)94'6&%'+$%5)&:7&-$#87':$9$A4:49#>'
PROTOCOL 4.4 Cardiomyopathy Management
4.8.1 Vital Sign AssessmentL*')9'$..'#7-4*'&6'84$%#'6$)."%4C'+$%5)&:7&-$#87':$9$A4:49#'34A)9*'<)#8'$9'$**4**:49#'&6'#84'-$#)49#=*'@)#$.'*)A9*'$95'&@4%$..'+&95)#)&9>'G$#)49#*'<)#8'+$%5)&:7&-$#8)4*'<)..'&6#49'8$@4'.&<'3.&&5'-%4**"%4*>',&<4@4%C'84$%#'6$)."%4'-$#)49#*'<)#8'*7*#&.)+'3.&&5'-%4**"%4*'34.&<'g1'::,AC'$.&9A'<)#8'T%'*)A9*'&6'54+&:-49*$#)&9'V#$+87+$%5)$C'%4*-)%$#&%7'5)*#%4**C'$.#4%45':49#$.'*#$#"*XC'*8&".5'34'8&*-)#$.)^45>
66 chronic care integration for endemic non-communicable diseases
4.8.2 Fluid Status AssessmentH84'94E#'*#4-')9'#84':$9$A4:49#'&6'+$%5)&:7&-$#87')*'4@$."$#)&9'&6'
5)"%4#)+'5&*4*'*8&".5'9&#'34'%45"+45')6'34#$23.&+P4%*'$%4'A&)9A'#&'34'$5545'&%')9+%4$*45'$#'#84'*$:4'@)*)#>'H8)*')*'34+$"*4C')9'#84'*8&%#2#4%:C'
4.8.3 Titration of Mortality-Reducing Medications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
L#'#84'*4+&95'@)*)#C'#84'LSU')98)3)#&%':$7'34')9+%4$*45>'?9'#8)*':$994%C':45)+$#)&9*'$%4')9+%4$*45'&94'$#'$'#):4'"9#).'A&$.'5&*4*'$%4'$+8)4@45'&%'5&*42.):)#)9A'*)54'4664+#*'&++"%>
chapter!4 | heart failure 67
4.8.3.1 Beta-Blockers in Heart Failure!4#$23.&+P4%*'$%4'$'+.$**'&6'5%"A*'#8$#'<&%P'&9'%4+4-#&%*')9'#84'84$%#'#&'*.&<'84$%#'%$#4'$95'%45"+4'#84'<&%P'#84'84$%#':"*+.4':"*#'5&'<)#8'4$+8'*O"44^4>'?9'.$%A4'%$95&:)^45'#%)$.*C'+4%#$)9'#7-4*'&6'34#$23.&+P4%*'8$@4'3449'*8&<9'#&'%45"+4'#84'%)*P'&6'54$#8')9'-$#)49#*'<)#8'+$%5)&2:7&-$#8)4*'37'$%&"95'B1m>J]2B/'!4#$23.&+P4%*'*8&<9'#&'-%&.&9A'.)64')9'#84*4'84$%#'6$)."%4'-$#)49#*')9+."54'+$%@45).&.C':4#&-%&.&.'*"++)9$#4C'$95'3)*&-%&.&.>
L#49&.&.')*'#84'34#$23.&+P4%':&*#'&6#49'$@$).$3.4')9'.&<2%4*&"%+4'*4#2
J11g'_,b':&54.'5%"A'6&%:".$%7'V#8&"A8'$*'$'#%4$#:49#'6&%'$9A)9$C'9&#'6&%'84$%#'6$)."%4X>BJ'a96&%#"9$#4.7C'#84%4')*'9&'-%&*-4+#)@4C'%$95&:)^45'5$#$'#&'*"--&%#')#*'"*4')9'-$#)49#*'<)#8'+$%5)&:7&-$#8)4*>BB
?9'+&:-$%)9A'#84'-%)+4'&6'84$%#'6$)."%4'34#$23.&+P4%*'V$..'A494%)+'$#'#8)*'-&)9#XC'<4'8$@4'6&"95'#84'-%)+4'&6'+$%@45).&.'#&'34'#84'.&<4*#'#8%&"A8'&"%'"*"$.'5)*#%)3"#&%*'V*44 APPENDIX BX>'_4'8$@4'D"5A45'#8$#'#84'
2
TABLE 4.15 Mortality-Reducing Medications for Cardiomyopathy
Beta-blocker
Starting dose Dose change Target dose
Carvedilol 3.125–6.25 mg 2x/day 3.125–6.25 mg 2x/day 25 mg 2x/day
Atenolol* 12.5 mg 1x/day 12.5 mg 1x/day 50 mg 1x/day
ACE inhibitor
Starting dose Dose change Target dose
Lisinopril 5 mg 1x/day 5 mg 1x/day 20 mg 1x/day
Captopril 12.5 mg 3x/day 12.5 mg 3x/day 50 mg 3x/day
Enalapril 2.5 mg 2x/day 2.5 mg 2x/day 10–20 mg 2x/day
Hydralazine/isosorbide dinitrate(Contraindications to beta-blocker and/or ACE inhibitor)
Starting dose Dose change Target dose
Hydralazine 25 mg 3x/day 25 mg 3x/day 50 mg 3x/day
Isosorbide 10 mg 3x/day 10 mg 3x/day 30 mg 3x/day
Potassium-sparing diuretic
Starting dose Dose change Target dose
Spironolactone 12.5–25 mg 1x/day 12.5 mg 1x/day 25 mg 1x/day
* Only if no carvedilol or other heart failure beta-blocker available.
68 chronic care integration for endemic non-communicable diseases
L#49&.&.'+$9'34'"*45')6'9&'84$%#'6$)."%4'34#$23.&+P4%')*'$@$).$3.4>
!4#$23.&+P4%*'*8&".5'34'"*45'<)#8'+$"#)&9')9'-$#)49#*'<)#8'+$%5)&:7&-2
4@49'#8&"A8'#847'*#$3).)^4'@&.":4'*#$#"*'&@4%'#84'.&9A'#4%:>'!4#$23.&+P4%*'*8&".5'34'*#$%#45'&9.7'<849'$'-$#)49#')*'4"@&.4:)+'$95'*8&".5'9&#'34'*#$%#45'&%')9+%4$*45'$#'#84'*$:4'#):4'#8$#'5)"%4#)+*'$%4'%45"+45>'F)P4<)*4C'#847'*8&".5'9&#'34'*#$%#45'&%')9+%4$*45')9'#84'*4##)9A'&6'.&<'
&6'34#$23.&+P4%*')9+."54'$AA%$@$#)&9'&6'$*#8:$'*7:-#&:*C'3%$57+$%5)$C'$95'87-1*)&9>
PROTOCOL 4.5'-%&@)54*'A")5$9+4'&9'34#$23.&+P4%'#)#%$#)&9')9'+$%5)&:72&-$#87>
NOYES
YES
YES
NO
NO
YES
NO
Increasebeta-blocker
dose(Table 4.15)
Cardiomyopathy, diuretic adjustments made
HR 50–60 bpm
HR ≤ 50 bpmOR
SBP ≤ 80 bpm
Decrease or do not startbeta-blocker
Fluid overload
(Table 4.9)
Maintain or do not start
beta-blocker
Maintain or do not start
beta-blocker
At target dose of beta-blocker (Table 4.15)
ORplan to increase
ACE inhibitorOR
decrease diuretic
chapter!4 | heart failure 69
4.8.3.2 ACE InhibitorsLSU')98)3)#&%*'$%4'$'+.$**'&6':45)+$#)&9'#8$#'<&%P'&9'#84'P)5947*C'3.&&5'
%4#49#)&9'$95'-%4@49#'8$%:6".'%4:&54.)9A'&6'84$%#':"*+.4>'H847'8$@4'3449'*8&<9'#&'%45"+4':&%#$.)#7'37'$%&"95'B1m')9'-$#)49#*'<)#8'+$%25)&:7&-$#8)4*>BK2B]'L.#8&"A8'$..'LSU')98)3)#&%*'$%4'$++4-#$3.4'6&%'"*4C'.)*)9&-%).'8$*'#84'.&<4*#'+&*#'$95'%4O")%4*'&9.7'&9+4'-4%'5$7'5&*)9A'V*44'TABLE 4.15'$95'APPENDIX BX>
?9'#84'-%4*49+4'&6'%49$.'6$)."%4C'LSU')98)3)#&%*'+$9'+$"*4'$'5$9A4%&"*'
5FX'*8&".5'9&#'34'-.$+45'&9'$9'LSU')98)3)#&%'"9.4**'-&#$**)":'.4@4.*'
PROTOCOL 4.5 Beta-Blocker Titration in Cardiomyopathy
70 chronic care integration for endemic non-communicable diseases
+$9'34'4$*).7':&9)#&%45'$#'%4A".$%')9#4%@$.*>'LSU')98)3)#&%*'$.*&'+$"*4'3)%#8'5464+#*'$95'*8&".5'94@4%'34'"*45')9'<&:49'<8&'$%4'-%4A9$9#>'F)P4'34#$23.&+P4%*C'LSU')98)3)#&%*'+$9'+$"*4'.&<'3.&&5'-%4**"%4'$95'*8&".5'34'$@&)545')9'-$#)49#*'<)#8'$'*7*#&.)+'3.&&5'-%4**"%4'.4**'#8$9'g1'::,A>'
PROTOCOL 4.6'-%&@)54*'A")5$9+4'&9'#)#%$#)&9'&6'LSU')98)3)#&%*')9'+$%5)&2:7&-$#87>'
4.8.3.3 Hydralazine and Isosorbide Dinitrate,75%$.$^)94')*'$9'$%#4%)&.$%'5).$#&%C'$95')*&*&%3)54'5)9)#%$#4')*'$'@49&5)2.$#&%>'_849'"*45')9'+&:3)9$#)&9C'#847'8$@4'3449'*8&<9')9'.$%A4'+.)9)+$.'#%)$.*'#&'54+%4$*4'#84'%)*P'&6'54$#8'37'$3&"#'B1m'$95'):-%&@4'84$%#'6$).2"%4'*7:-#&:*C'$.#8&"A8'#847'$%4'9&#'$*'4664+#)@4'$*'LSU')98)3)#&%*>Bg2K1',75%$.$^)94'$95')*&*&%3)54'8$@4'#84'$5@$9#$A4'&6'$664+#)9A'84$%#'%$#4'$95'%49$.'6"9+#)&9'.4**'#8$9'34#$23.&+P4%*'$95'LSU')98)3)#&%*>'H847'$%4'*$64'#&'"*4'<849'3%$57+$%5)$'.):)#*'34#$23.&+P4%'"*4'$95i&%'<849'%49$.'6"9+#)&9'-%&8)3)#*'LSU')98)3)#&%'"*4>',&<4@4%C'#8)*'5%"A'+&:3)9$#)&9')*'4E-49*)@4C')#'%4O")%4*')9+&9@49)49#'#8%442#):4*2$25$7'5&*)9AC'$95')#'
-$#)49#'$584%49+4>'[&%'#84*4'%4$*&9*C'<4'A494%$..7'%4*4%@4'#84'"*4'&6'875%$.$^)94i)*&*&%3)54'5)9)#%$#4'6&%'-$#)49#*'<)#8'+&9#%$)95)+$#)&9*'#&'34#$23.&+P4%*'$95i&%'LSU')98)3)#&%*>'L*'<)#8'T%'84$%#'6$)."%4':45)+$2#)&9*C'+$"#)&9'*8&".5'34'4E4%+)*45'<849'*#$%#)9A'&%')9+%4$*)9A'#84*4':45)+$#)&9*')9'-$#)49#*'<8&*4'3.&&5'-%4**"%4')*'.4**'#8$9'd1'::,A>'
PROTOCOL 4.6'$.*&'-%&@)54*'A")5$9+4'&9'#)#%$#)&9'&6'875%$.$^)94i)*&*&%23)54')9'+$%5)&:7&-$#87>
NO
YES
YES NO
NO
YESNO
NO
YES
NO
YES
YESNO
IncreaseACE inhibitor(Table 4.15)
Creatinine ≥ 200 µmol/L
AND/OR K ≥ 5.5 mEq/L?
Start,continue or
increasehydralazine
andisosorbidedinitrate
(Table 4.15)
Stop/donot start
ACEinhibitors
MaintainACE inhibitor
dose
SBP ≥ 90 mmHg
SBP ≤ 90
mmHg
Decrease/do not start
ACE inhibitor
Wait to start ordecrease
hydralazineand isosorbide
dinitrate(Table 4.15)
Able to checkcreatinine AND/OR
potassium?Pregnant
K ≥ 6.5 mEq/L
Admit, treathyperkalemia(Section 6.5)
Decrease or maintain ACE inhibitor
Cardiomyopathy, diuretic and beta-blocker adjustments made
At ACE inhibitor
goal dose OR increasing beta-blocker?
chapter!4 | heart failure 71
PROTOCOL 4.6 ACE-Inhibitor Titration and Use of Hydralazine/Isosorbide in Cardiomyopathy
4.8.3.4 SpironolactoneL*'54*+%)345')9'SECTION 4.7.3C'*-)%&9&.$+#&94'+$9'34'$'"*46".'$5D"9+#)@4'5)"%4#)+')9'+$*4*'&6'$*+)#4*>'F)P4'LSU')98)3)#&%*C'*-)%&9&.$+#&94'+$9'+$"*4'$'%)*4')9'*4%":'-&#$**)":C'4*-4+)$..7')9'#84'-%4*49+4'&6'%49$.'6$)."%4>''?#'*8&".5'34'$@&)545')6'#84'+%4$#)9)94'.4@4.')*'A%4$#4%'#8$9'J11'n:&.iF'
<)#8'+8%&9)+$..7'.&<'-&#$**)":'*4+&95$%7'#&'#84'"*4'&6'6"%&*4:)54'&%'875%&+8.&%)$^)54>'Y-)%&9&.$+#&94'8$*'$.*&'3449'*8&<9'#&'%45"+4':&%#$.)#7'37'B1m')9'-$#)49#*'<)#8'.46#'@49#%)+".$%'57*6"9+#)&9'<8&'$%4'$.%4$57'#$P)9A'LSU')98)3)#&%*>K/CKJ'TABLE 4.15'*8&<*'%4+&::49545'5&*)9A>
YES
NO
YES
YES
YES
NO
NO
NO
NO
NO
YES
NO
YES
YES
YES
Refer tofamily
planning
Womanbetween 15 and 49
years
PeripartumCMP?
Aspirin
HIV?
Refer toinfectious
diseaseclinic
AlcoholCMP?Abstinence
Spironolactone(Table 4.15)
Atrialfibrillation by
ECG
Start warfarin(see Chapter 5)
Irregularheart rhythm
ClassIII or IV
symptomsDigoxin
(Table 4.16)
Patient with cardiomyopathy, diuretic, beta-blocker and ACE inhibitor/hydralazine/isosorbide adjustments made
Ascites OR
K ≤ 3.5 mEq AND Cr ≤ 100 µmol/L AND SBP ≥ 90
72 chronic care integration for endemic non-communicable diseases
4.8.4 Other Medications in Cardiomyopathy Management(4-495)9A'&9'#84'*"*-4+#45'4#)&.&A7'&6'+$%5)&:7&-$#87'$95i&%'5)*4$*4'+&6$+#&%*C'+4%#$)9'$5D"9+#)@4':45)+$#)&9*':$7'34')95)+$#45>'PROTOCOL 4.72-%&@)54*'A")5$9+4'&9'"*)9A'#84*4'T%':45)+$#)&9*>'
PROTOCOL 4.7 Other Medication Needs for Cardiomyopathy Patients
chapter!4 | heart failure 73
TABLE 4.16 Digoxin Dosing
Starting dose Maximum dose
0.125 mg/day 0.25 mg/day
4.8.4.1 Digoxin (Digitalis)()A&E)9')*'&94'&6'#84'&.54*#'$95':&*#'<)54.7'$@$).$3.4':45)+$#)&9*'6&%'#84'#%4$#:49#'&6'84$%#'6$)."%4>'?#'$+#*'#&')9+%4$*4'#84'-":-)9A'6"9+#)&9'
)*'-%4*49#>'a*)9A'5)A&E)9'+$9'):-%&@4'*7:-#&:*')9'-$#)49#*'<)#8'84$%#'6$)."%4>',&<4@4%C')9'$'.$%A4'+.)9)+$.'#%)$.C')#'5)5'9&#'54+%4$*4':&%#$.2)#7>KB'L.*&C'$#'8)A8'5&*4*C'#&E)+)#7'+$9'54@4.&-C'<8)+8'<)..'%4*".#')9'@)*"$.'+8$9A4*C'5)^^)94**C'&%'9$"*4$C'$95'+$9'.4$5'#&'5$9A4%&"*'$%%87#8:)$*>'H&E)+)#7'<)..'&++"%')6'5)A&E)9')*'"*45')9'-$#)49#*'<)#8'%49$.'6$)."%4C'*&'#8)*'
KK'_4'%4*4%@4'5)A&E)9'6&%'-$#)49#*'<)#8'+.$**'???'&%'?\'84$%#'6$)."%4'*7:-#&:*>'
84.-'<)#8'%$#4'+&9#%&.>'
TABLE 4.16'.)*#*'%4+&::49545'5)A&E)9'5&*)9A>
4.8.4.2 Aspirin_849'#84'84$%#'5&4*'9&#'-":-'<4..C'3.&&5'#495*'#&'*)#'*#)..')9*)54'#84'84$%#'$95':$7'6&%:'+.&#*C'<8)+8'+$9'#849'4:3&.)^4'V#%$@4.'#&'T%'-$%#*'&6'#84'3&57XC'+$"*)9A'*#%&P4'&%'T%'+$#$*#%&-8)+'4@49#*>'G4%)-$%#":'+$%5)&:7&-$#87'-$#)49#*'$%4'$#'-$%#)+".$%.7'8)A8'%)*P'6&%'#8)*C'$*'<4..'$*'6&%'@49&"*'+.&#*>'H847'*8&".5'34'*#$%#45'&9'/11':A'&6'$*-)%)9'5$).7'#&'84.-'#8)9'#84'3.&&5>'G$#)49#*'<)#8'4@)549+4'&6'$9'$+#)@4'+.&#'<)..'9445'*#%&9A4%'$9#)+&$A".$#)&9'V*44'CHAPTER 5X>
4.8.4.3 Birth ControlL..'64:$.4'-$#)49#*'&6'+8).534$%)9A'$A4'*8&".5'34'+&"9*4.45'&9'#84'5$92A4%*'&6'-%4A9$9+7')9'#84'*4##)9A'&6'$'+$%5)&:7&-$#87>'H84'-87*)&.&A)+'
*:$..4%'."9A'@&.":4*C':4$9'#8$#'84$%#'6$)."%4'*7:-#&:*'$.:&*#'$.<$7*'<&%*49>'?9'#84'+$*4'&6'-4%)-$%#":'+$%5)&:7&-$#87C'*"3*4O"49#'-%4A29$9+)4*'+$9'34'.4#8$.>'L..'<&:49'*8&".5'34'$5@)*45'#&'"*4'3)%#8'+&9#%&.>'S.)9)+)$9*'*8&".5'<&%P'<)#8'6$:).72-.$99)9A'*#$66'#&'+&&%5)9$#4'466&%#*'$95'49*"%4'#8$#'<&:49'$#'%)*P'%4+4)@4'#):4.7'$95'$--%&-%)$#4'3)%#8'+&9#%&.>'Y44'CHAPTER 3'6&%'6"%#84%'5)*+"**)&9'&6'3)%#8'+&9#%&.'6&%'<&:49'<)#8'84$%#'6$)."%4>'
4.8.4.4 Antiretrovirals (ARVs)a9#%4$#45',?\')964+#)&9'6%4O"49#.7'.4$5*'#&'+$%5)&:7&-$#87>K0CKZ'G%45)+2#&%*'&6',?\'+$%5)&:7&-$#87'$%4'&--&%#"9)*#)+')964+#)&9'$95'.49A#8'&6'
74 chronic care integration for endemic non-communicable diseases
#):4'*)9+4',?\'5)$A9&*)*>'L..'-$#)49#*'<)#8'$'94<.7'5)$A9&*45'+$%5)&:72&-$#87'*8&".5'34'#4*#45'6&%',?\>'?6'$'-$#)49#')*',?\'-&*)#)@4C'%4A$%5.4**'&6'#84'S(K'+&"9#C'#84'-$#)49#'*8&".5'34'#%4$#45'<)#8'L;\*'$++&%5)9A'#&'.&+$.'-%&#&+&.*>
4.9 Hypertensive Heart Disease Etiology and Diagnosis
,7-4%#49*)&9'+%4$#4*'*#%4**'&9'#84'84$%#C'<8)+8'8$*'#&'<&%P'8$%54%'#&'-"*8'3.&&5')9#&'$'8)A82-%4**"%4'*7*#4:>'?9'%4*-&9*4'#&'#8)*'<&%P.&$5C'#84'84$%#':"*+.4'A4#*'#8)+P4%'V87-4%#%&-87X'$95'*#)664%>'H8)*'+8$9A4'542
<$..>'a*"$..7C'-$#)49#*'<)#8'87-4%#49*)@4'84$%#'5)*4$*4'<)..'8$@4'9&%:$.'&%'&9.7':).5.7'54-%4**45'*7*#&.)+'6"9+#)&9'V4D4+#)&9'6%$+#)&9'34#<449'K1m'$95'01mX'<)#8'.46#'@49#%)+".$%'87-4%#%&-87C'3"#'*&:4'+$9'-%&A%4**'#&'@4%7'.&<'4D4+#)&9'6%$+#)&9*>'
,7-4%#49*)@4'84$%#'5)*4$*4'%4*".#*'6%&:'.&9A2*#$95)9AC'*4@4%4'87-4%#492*)&9>'H84'87-4%#49*)&9')#*4.6':$7'34')5)&-$#8)+'V<8)+8')*':&*#'+&::&9X'&%'*4+&95$%7'#&'$9T%'-%&3.4:'V*"+8'$*'$'P)5947'&%'495&+%)94'5)*2
*"*-4+#45o*4@4%4'%49$.'6$)."%4')9'-$%#)+".$%o$.#8&"A8'87-4%#49*)&9')#*4.6'+$9'+$"*4'%49$.'6$)."%4>'
H%4$#:49#'&6'87-4%#49*)@4'84$%#'5)*4$*4')9+."54*'+&9#%&.'&6'@&.":4'*#$2#"*'$95'3.&&5'-%4**"%4>'PROTOCOL 4.82-%&@)54*'$9'&"#.)94'6&%'87-4%#492*)@4'84$%#'5)*4$*4':$9$A4:49#>
Suspected or confirmedhypertensive heart disease
Assess fluid status,adjust furosemide dose
(Protocol 4.3, Tables 4.9 and 4.12)
Assess blood pressureand adjust hypertensive
medications(Protocol 4.9)
Follow-upplanning
(Section 4.13,Table 4.23)
Assessmedication
contraindicationsand side e!ects(Protocol 4.10)
chapter!4 | heart failure 75
PROTOCOL 4.8 Management of Suspected or Confirmed Hypertensive Heart Disease
4.9.1 Vital Sign AssessmentL*'<)#8'$..'#7-4*'&6'84$%#'6$)."%4C':$9$A4:49#'&6'87-4%#49*)@4'84$%#'5)*4$*4'34A)9*'<)#8'$9'$**4**:49#'&6'#84'-$#)49#=*'@)#$.'*)A9*'$95'&@4%$..'+&95)#)&9>'(4+&:-49*$#)&9')9'-$#)49#*'<)#8'87-4%#49*)@4'84$%#'5)*4$*4'
%4*".#)9A')9'*#)6649)9A'&6'#84'84$%#>'L*'54*+%)345')9'CHAPTER 8C'#84'$--%&$+8')9'#8)*'*)#"$#)&9')*'#&'.&<4%'#84'3.&&5'-%4**"%4'A%$5"$..7o'
4.9.2 Fluid Status AssessmentH84'94E#'*#4-')9'#84':$9$A4:49#'&6'87-4%#49*)@4'84$%#'5)*4$*4')*'#84'
SECTION 4.7C'TABLE 4.9C'$95'PROTOCOL 4.3>
4.9.3 Titration of Antihypertensives?9'&%54%'#&'-%4@49#'<&%*49)9A'84$%#'6$)."%4'*7:-#&:*C'$9#)87-4%#492
76 chronic care integration for endemic non-communicable diseases
TABLE 4.17 Antihypertensives for Hypertensive Heart Disease
First-line drug (ACE inhibitor)
Initial dose Dose increase Maximum dose
Side e"ects/cautions
Lisinopril 5 mg 1x/day 5 mg 1x/day 20 mg 1x/day 1. Birth defects (contraindicated in pregnancy)2. Chronic non-productive cough3. High potassium4. Worsened renal function
Captopril 12.5 mg 3x/day 12.5 mg 3x/day 50 mg 3x/day
Second-line drug (thiazide)
Initial dose Dose increase Maximum dose
Side e"ects/cautions
Hydrochlorothiazide 12.5 mg 1x/day 12.5 mg 1x/day 25 mg 1x/day Lowers potassium
Third-line drug (CCB)*
Initial dose Dose increase Maximum dose
Side e"ects/cautions
Amlodipine 5 mg 1x/day 5 mg 1x/day 10 mg 1x/day Lower-extremity swelling
Nifedipine (sustained release)
20 mg 2x/day 20 mg 2x/day 40 mg 2x/day
Fourth-line drug (beta-blocker)
Initial dose Dose increase Maximum dose
Side e"ects/cautions
Atenolol 25 mg 1x/day 25 mg 1x/day 50 mg 1x/day 1. Bradycardia2. Renally excreted 3. Decrease dose for renal failure
Fifth-line drug (vasodilator)
Initial dose Dose increase Maximum dose
Side e"ects/cautions
Hydralazine 25 mg 3x/day 25 mg 3x/day 50 mg 3x/day 1. Headache2. Tachycardia3. Lower-extremity swelling
* CCB = Calcium-channel blocker
Y44'PROTOCOL 4.9C'PROTOCOL 4.10C'$95'TABLE 4.17>'?9'A494%$.C'$9'LSU'
4E)*#>'?6'#84'3.&&5'-%4**"%4')*'9&#'+&9#%&..45'&%')6'LSU')98)3)#&%*'$%4'9&#'$--%&-%)$#4'6&%'#84'-$#)49#C'$'#8)$^)54'5)"%4#)+':$7'34'*#$%#45>'L6#4%'#8$#C'$:.&5)-)94C'$'-4%)-84%$..7'$+#)9A'+$.+)":2+8$994.'3.&+P4%C'*8&".5'34'"*45>'!4#$23.&+P4%*'$95'875%$.$^)94'$%4'#8)%52'$95'6&"%#82.)94':45)+$2#)&9*C'%4*-4+#)@4.7>
YES
NO
YES
NO
YES
NO
YES
BP ≥160/100mmHg
Add 2 drugs ORincrease 2 drug dosesif already on 4 drugs
Add 1 drug ORincrease 1 drug doseif already on 4 drugs
BP ≥ 130/80≤ 160/100
mmHg
BP ≥ 90/70
BP ≤ 90/70
≤ 130/80mmHg
mmHg
Maintain currentmedications
Decrease currentmedications
Hypertensive heart diseasediuretic dose adjustments already made
chapter!4 | heart failure 77
PROTOCOL 4.9 Antihypertensive Management in Hypertensive Heart Disease
YES
YES
YES
NO
NO
Pregnant,Cr ≥ 200 µmol/L
AND/OR K ≥ 5.5 mEq/L?
Stop or do not startcaptopril/lisinopril AND/OR
spironolactone.
HR ≤ 50bpm?
Reduce, stop or do not startbeta-blocker
K ≥ 6.5mEq/L
Admit, treathyperkalemia(Section 6.5)
Suspected or confirmed hypertensiveheart disease, diuretic and
anti-hypertensive adjustments made
78 chronic care integration for endemic non-communicable diseases
PROTOCOL 4.10 Assessment of Medication Contraindications and Side E"ects in Management of Hypertensive Heart Disease
4.10 Mitral Stenosis
R)#%$.'*#49&*)*')*'$'*-4+)$.'#7-4'&6'@$.@".$%'5)*4$*4'<)#8'$'#%4$#:49#'-$#8<$7'#8$#'5)664%*'6%&:'#8$#'&6'T%'@$.@".$%'5)*4$*4*>'a9#%4$#45C':)#%$.'*#49&*)*'.4$5*'#&'.46#'$#%)$.'49.$%A4:49#C'-".:&9$%7'87-4%#49*)&9C'$95'%)A8#'@49#%)+".$%'6$)."%4>'H84'*#%4#+845'.46#'$#%)":')*'-$%#)+".$%.7'-%&94'#&'54@4.&-)9A'4.4+#%)+$.'$39&%:$.)#)4*C'.4$5)9A'#&'$#%)$.'$%%87#82:)$*>'R)#%$.'*#49&*)*'$.:&*#'$.<$7*'%4*".#*'6%&:'"9#%4$#45'%84":$#)+'84$%#'5)*4$*4>'R)#%$.'*#49&*)*')*':&*#'+&::&9')9'-4&-.4'34#<449'B1'$95'01'74$%*'&.5'V$.#8&"A8')#':$7'*&:4#):4*'&++"%')9'7&"9A4%'&%'&.54%'-$#)49#*X>'b6#49'<&:49'<)..'54@4.&-'*7:-#&:*')9'#84':)55.4'&6'#84)%'-%4A9$9+)4*>'G$#)49#*'<)#8':)#%$.'*#49&*)*'$%4'$.*&'$#'8)A8'%)*P'&6'$#%)$.'
25)&A%$-87'+$9'4$*).7')549#)67'$'*#49&#)+':)#%$.'@$.@4C'<8)+8'8$*'$'8)A8.7'%4+&A9)^$3.4'-$##4%9')9'#84'-$%$*#4%9$.'.&9A'@)4<>'
YES
YES
NO
YES
YES
NO
NO
NO
NO
YES
HR ≥ 60bpm andSBP ≥ 90mmHg?
Start/increaseatenolol if not
contraindicated(Table 4.10)
Atrialfibrillation(on ECG)
AND/OR priorstroke
Aspirin 100mg 1x/day
Start warfarin iffeasable and notcontraindicated,
otherwise give aspirin(Chapter 5)
Suspected RHD and
≤ 40 years old?
Refer tofamily planning(Section 3.5)
Penicillinprophylaxis(Table 9.5)
Female, agebetween 15
and 49?
Mitralstenosis
Assess fluid status,adjust furosemide dose
(Protocol 4.3, Tables 4.9 and 4.12)
Assess vital signs and clinicalstatus. Treat and refer
decompensated heart failure
Surgical candidate?
Follow-up planning(Section 4.13, Table 4.23)
Surgical planning(Chapter 5)
chapter!4 | heart failure 79
R)#%$.'*#49&*)*'%4O")%4*'$'5)664%49#'#%4$#:49#'*#%$#4A7'#8$9'T%'6&%:*'&6'@$.@".$%'84$%#'5)*4$*4>'H84'A&$.*'&6':45)+$.'#84%$-7'$%4'#&':$9$A4'
+$%5)$+'&"#-"#'37'+&9#%&..)9A'84$%#'%$#4>'PROTOCOL 4.11'&"#.)94*'#84'*#4-*')9'#84':45)+$.':$9$A4:49#'&6':)#%$.'*#49&*)*>'
PROTOCOL 4.11 Management of Mitral Stenosis
80 chronic care integration for endemic non-communicable diseases
4.10.1 Vital Sign AssessmentL*'<)#8'$..'#7-4*'&6'84$%#'6$)."%4C':)#%$.'*#49&*)*':$9$A4:49#'34A)9*'<)#8'$9'$**4**:49#'&6'#84'-$#)49#=*'@)#$.'*)A9*'$95'&@4%$..'+&95)#)&9>'G$#)49#*'<)#8':)#%$.'*#49&*)*'$%4'-$%#)+".$%.7'*49*)#)@4'#&'#$+87+$%5)$'$95'<)..'9&#'34'$3.4'#&'#&.4%$#4'6$*#'84$%#'%$#4*'<4..>
4.10.2 Fluid Status Assessment
*#$#"*'$95'#)#%$#)&9'&6'5)"%4#)+*>'H84'-%)9+)-.4*'84%4'$%4'#84'*$:4'$*')9'T%'6&%:*'&6'84$%#'6$)."%4>'Y44'SECTION 4.7C'TABLE 4.9C'$95'PROTOCOL 4.3>
4.10.3 Control of Heart Rate_849'#84':)#%$.'@$.@4'5&4*9=#'&-49'<4..C'.4**'3.&&5'+$9':&@4'6%&:'#84'.46#'$#%)":'#&'#84'.46#'@49#%)+.4'5"%)9A'5)$*#&.4>'H8)*C')9'#"%9C'54+%4$*4*'#84'$:&"9#'&6'3.&&5'#84'84$%#'+$9'-":-'&"#'<)#8'4$+8'34$#>'_849'#84'
*8&%#4%C'4E$+4%3$#)9A'#84'-%&3.4:>'[&%'#8)*'%4$*&9C')#')*'@4%7'):-&%#$9#'#&'+&9#%&.'84$%#'%$#4C'-%464%$3.7'P44-)9A')#'34.&<'Z1'34$#*'-4%':)9"#4C')6'-4%:)##45'37'3.&&5'-%4**"%4>'_4'%4+&::495'#84'"*4'&6'34#$23.&+P4%*'6&%'#8)*'-"%-&*4>'L..'34#$23.&+P4%*'<&%P'4O"$..7'<4..')9'54+%4$*)9A'84$%#'%$#4>'_4'*"AA4*#'"*)9A'$#49&.&.'34+$"*4'&6')#*'&9+42$25$7'5&*)9AC'.&<'+&*#C'$95'<)54'$@$).$3).)#7>',&<4@4%C'$97'$A49#'#8$#'*.&<*'#84'84$%#'%$#4':$7'34'"*45>'
6$*#'84$%#'%$#4*>'G$#)49#*'<)#8':)#%$.'*#49&*)*'$%4'"9$3.4'#&'#&.4%$#4'#84*4'6$*#'84$%#'%$#4*'$95'<)..'34+&:4'@4%7'*)+P'&%'4@49'5)4')6'#84'$%%87#8:)$'
$95':)#%$.'*#49&*)*'+$99&#'34'&3#$)945'<)#8'34#$23.&+P4%*'$.&94C'&%')6'3.&&5'-%4**"%4'.):)#*'#84'"*4'&6'34#$23.&+P4%*C'+.)9)+)$9*':$7'-%4*+%)34'
TABLE 4.18'$95'SECTION 4.16.1>X
TABLE 4.18 Medications to Reduce Heart Rate in Mitral Stenosis
Medication Initial dose Dose increase Maximum dose
Beta-blocker (for use in sinus tachycardia or atrial fibrillation)
Atenolol 12.5 mg 1x/day 12.5 mg 1x/day 50 mg 1x/day
Digoxin (only if tachycardia and atrial fibrillation)
Digoxin 0.125 mg 1x/day 0.125 mg 1x/day 0.25 mg 1x/day
chapter!4 | heart failure 81
4.10.4 Other Medications in Management of Mitral Stenosis4.10.4.1 Penicillin;84":$#)+'84$%#'5)*4$*4'+$"*4*'$.:&*#'$..'+$*4*'&6':)#%$.'*#49&*)*')9'%4*&"%+42-&&%'*4##)9A*>'L*'54*+%)345')9'CHAPTER 9C'-%4@49#)&9'&6'6"%#84%'$##$+P*'&6'%84":$#)+'64@4%'#8%&"A8'-49)+)..)9'-%&-87.$E)*'84.-*'*.&<'#84'-%&A%4**)&9'&6'%84":$#)+'@$.@".$%'5)*4$*4>'L.#8&"A8'%84":$#)+'64@4%'A494%$..7'$664+#*'*+8&&.2$A45'+8).5%49C'<4'%4+&::495'-49)+)..)9'-%&-87.$E)*'6&%'$..'-$#)49#*'<)#8'%84":$#)+'@$.@".$%'5)*4$*4'"954%'#84'$A4'&6'K1>'Y44'SECTION 9.2$95'$5:)9)*#%$#)&9>'
4.10.4.2 Birth ControlL*'<)#8'+$%5)&:7&-$#87C':)#%$.'*#49&*)*'-%4*49#*'$9')9+%4$*45'5$9A4%'#&'<&:49'5"%)9A'-%4A9$9+7C'$95'6&%'*&:4'-%4A9$9#'<&:49C')#'+$9'34'
*#49&*)*')9'#84'J95'&%'B%5'#%):4*#4%>'_&:49'34#<449'#84'$A4*'&6'/0'$95'Kd'74$%*'<)#8':)#%$.'*#49&*)*'*8&".5'%4+4)@4'6$:).7'-.$99)9A'+&"9*4.)9A'$95'34'&664%45'$9'$++4-#$3.4'6&%:'&6'3)%#8'+&9#%&.'V*44'CHAPTER 3X>
4.10.4.3 Anticoagulation (Aspirin and Warfarin)L..'-$#)49#*'<)#8':)#%$.'*#49&*)*'$%4'$#'@4%7'8)A8'%)*P'&6'54@4.&-)9A'+.&#*')9'#84)%'5).$#45C'*#$A9$9#'.46#'$#%)":>'H84*4'+.&#*'8$@4'$'8)A8'.)P4.)8&&5'
)9+%4$*4*'#84'+8$9+4*'&6'+.&#'6&%:$#)&9'$95'*#%&P4C'$95'-$#)49#*'<)#8'
$..'-$#)49#*'<)#8':)#%$.'*#49&*)*'*8&".5'%4+4)@4'*&:4'#7-4'&6'3.&&52
*#%&9A4%'$9#)+&$A".$#)&9')9'#84'6&%:'&6'<$%6$%)9'*8&".5'34')9)#)$#45')6'#84%4'$%4'9&'+&9#%$)95)+$#)&9*'#&'<$%6$%)9'#84%$-7'V*44'CHAPTER 5X>'?6'
-%4*+%)345>
4.11 Other Valvular and Congenital Heart Disease
H8)*'+$#4A&%7'49+&:-$**4*'#84':&*#'5)@4%*4'A%&"-'&6'84$%#'6$)."%4'-$#)49#*>'a9.)P4'#84'-%4@)&"*.7'54*+%)345'84$%#'6$)."%4'+$#4A&%)4*C'#84*4'5)*4$*4*'&6#49'%4O")%4'$5@$9+45'4+8&+$%5)&A%$-87'*P)..*'6&%'5)664%49#)$2#)&9>'[&%#"9$#4.7C'#847'$.*&'*8$%4'$'+&::&9')9)#)$.'$--%&$+8')9':$9$A42:49#'V*44'PROTOCOL 4.12X>'_4'#84%46&%4'$%A"4'#8$#'$#'#84'5)*#%)+#'84$.#8'+49#4%'[email protected]'#84*4'-$#)49#*'+$9'34'*$64.7':$9$A45'$*'$9'"95)664%49#)$#45'
5)$A9&*)*>
\$.@".$%'5)*4$*4'V84%4'4E+."5)9A':)#%$.'*#49&*)*X':4$9*'#8$#'*&:4')9*".#'#&'#84'84$%#'@$.@4'V*"+8'$*'%84":$#)+'64@4%X'8$*'+$"*45')#'#&'4)#84%'9&#'
82 chronic care integration for endemic non-communicable diseases
<)..':&*#'&6#49'8$@4'5%$:$#)+':"%:"%*>'H84*4'.4*)&9*'+$9'4@49#"$..7'+$"*4'5).$#)&9'&6'#84'$**&+)$#45'84$%#'+8$:34%*C'<8)+8')9'#"%9'+$9'.4$5'#&'$'+$%5)&:7&-$#87>'\$.@".$%'5)*4$*4*'$%4'"*"$..7'*4+&95$%7'#&'%84"2:$#)+'84$%#'5)*4$*4C')9'<8)+8'"9#%4$#45'*#%4-#&+&++$.')964+#)&9'.4$5*'#&'$9'$"#&)::"94'%4*-&9*4'#8$#'%4*".#*')9'@$.@4'54*#%"+#)&9>
S&9A49)#$.'84$%#'5)*4$*4':4$9*'#8$#'#84'84$%#'<$*':$.6&%:45'$#'3)%#8>'S&9A49)#$.'5)*4$*4'+&:4*')9':$97'@$%)4#)4*'$95'&6#49'+$"*4*':"%:"%*>'?#'+$9'34'+$"*45'37'$'@$%)4#7'&6'A494#)+'6$+#&%*'$95i&%'#4%$#&A49*'V#&E)9*'5"%)9A'-%4A9$9+7X>
H8)*'+&..4+#)&9'&6'84$%#'6$)."%4'5)$A9&*4*')*'3'.$%A4%'$95':&%4'5)@4%*4'#8$9'#84'-%4@)&"*'+$#4A&%)4*>',&<4@4%C'#84*4'5)*4$*4*'*8$%4'$'+&::&9'-$#8<$7')9'#84)%')9)#)$.':45)+$.':$9$A4:49#>'R&%4&@4%C'5)664%49#)$#)&9'$:&9A'#84*4'5)*4$*4*'&6#49'%4O")%4*'$'8)A84%'.4@4.'&6'4+8&+$%5)&A%$-8)+'$95'T%'5)$A9&*#)+'*P)..*'#8$9'$%4'%4$*&9$3.7'$##$)9$3.4'37'A494%$.)*#'-87*)+)$9*'&%'$5@$9+45'9"%*4*')9'%4*&"%+42-&&%'*4##)9A*>
H84'+&::&9'A&$.*')9'#84':45)+$.':$9$A4:49#'&6'#8)*'A%&"-'&6'84$%#'
5)*4$*4'<)..'34'*"%A)+$.C'$95'#8"*'$..'-$#)49#*'*"664%)9A'#8)*'+.$**'&6'84$%#'6$)."%4'*8&".5'34'4@$."$#45'37'$'+$%5)&.&A)*#'&%'4E-4%)49+45')9#4%9)*#'&%'-45)$#%)+)$9'<)#8)9'Z'<44P*'#&'Z':&9#8*'&6'5)$A9&*)*>
NO
YES
Suspected or echocardiographically confirmedvalvular or congenital heart disease.
No evidence of mitral stenosis
Assess fluid status, adjust diuretic(Protocol 4.3, Tables 4.9 and 4.12)
Surgicalcandidate?
Follow-up planning(Section 4.13, Table 4.23)
Surgical planning(Chapter 5)
Assess creatinine, potassium andneed for ACE inhibitor
(Protocol 4.13)
Follow-up, surgical planning,consultation with a
cardiologist
Assess other medication needs(Protocol 4.14)
chapter!4 | heart failure 83
PROTOCOL 4.12 Valvular or Congenital Heart Disease Management (Excluding Mitral Stenosis)
4.11.1 Vital Sign AssessmentL*'<)#8'$..'#7-4*'&6'84$%#'6$)."%4C':$9$A4:49#'&6'#8)*'+&..4+#)&9'&6'84$%#'6$)."%4'#7-4*'34A)9*'<)#8'$9'$**4**:49#'&6'#84'-$#)49#=*'@)#$.'*)A9*'$95'&@4%$..'+&95)#)&9>
4.11.2 Fluid Status Assessment
&6'5)"%4#)+*>'Y44'SECTION 4.7C'TABLE 4.9C'$95'PROTOCOL 4.3>
NO
YES
NOYES
YES YES
NO
NO
Pregnant,creatinine ≥ 200µmol/L AND/ORK ≥ 5.5 mEq/L?
K ≥ 6.5 mEq/L
Able to checkcreatinine AND/OR
potassium?
SBP ≤ 100mmHg
Stop/do notstart ACEinhibitors
AtACE inhibitor
goal dose
MaintainACE inhibitor
dose
Valvular or congenitaldisease, diuretic
adjustments made
IncreaseACE inhibitor
Treat forhyperkalemia
(see Section 6.5)
84 chronic care integration for endemic non-communicable diseases
4.11.3 Titration of ACE Inhibitors ?9'-$#)49#*'<)#8'@$.@".$%'84$%#'5)*4$*4'V4E+."5)9A':)#%$.'*#49&*)*XC')#')*'):-&%#$9#'#&'%45"+4'#84'<&%P.&$5'&6'#84'84$%#'37'.&<4%)9A'#84'3.&&5'-%4**"%4>'H84'84$%#'<$*'54*)A945'#&'-":-'3.&&5')9'&9.7'&94'5)%4+#)&9>'
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k/J1'::,A>'PROTOCOL 4.13'&"#.)94*'$9'$--%&$+8'#&')9)#)$#)9A'$95'#)#%$#)9A'LSU')98)3)#&%*>'
PROTOCOL 4.13 ACE-Inhibitor Titration for Valvular or Congenital Heart Disease Management (Excluding Mitral Stenosis)
chapter!4 | heart failure 85
4.11.4 Other Medications4.11.4.1 SpironolactoneG$#)49#*'<)#8'5)*4$*4'&6'$97'&6'#84'@$.@4*'&9'#84'%)A8#'*)54'&6'#84'84$%#'+$9'54@4.&-'*7:-#&:*'&6'%)A8#'84$%#'6$)."%4C')9+."5)9A':$**)@4'$*+)#4*>'?9'#84*4'-$#)49#*C'*-)%&9&.$+#&94'+$9'34'$'"*46".'$5D"9+#'#&'6"%&*4:)54'V*44'TABLE 4.19X>'Y-)%&9&.$+#&94'*8&".5'9&#'34'"*45')9'-$#)49#*'<)#8'
87-4%P$.4:)$>'S&9+"%%49#'"*4'<)#8'$9'LSU')98)3)#&%'+$9'$.*&'+$"*4'5$9A4%&"*'87-4%P$.4:)$C'$95'#84*4'-$#)49#*'*8&".5'8$@4'-&#$**)":':&9)#&%45'4@4%7'*)E':&9#8*>'
4.11.4.2 PenicillinL*'54*+%)345')9'CHAPTER 9C'-49)+)..)9'-%&-87.$E)*'84.-*'*.&<'#84'-%&2A%4**)&9'&6'%84":$#)+'@$.@".$%'5)*4$*4'37'-%4@49#)9A'6"%#84%'$##$+P*'&6'%84":$#)+'64@4%>'L.#8&"A8'%84":$#)+'64@4%'A494%$..7'$664+#*'*+8&&.2$A45'+8).5%49C'<4'%4+&::495'-49)+)..)9'-%&-87.$E)*'6&%'$..'-$#)49#*'<)#8'%84":$#)+'@$.@".$%'5)*4$*4'"954%'#84'$A4'&6'K1>'Y44'SECTION 9.2'6&%'*-42
TABLE 4.19 Medications for Valvular/Congenital Heart Disease
Initial dose Dose adjustment Maximum dose
ACE inhibitor
Lisinopril 5 mg 1x/day 5 mg 1x/day 20 mg 1x/day
Captopril 12.5 mg 3x/day 12.5 mg 3x/day 50 mg 3x/day
Potassium-sparing diuretic
Spironolactone 12.5–25 mg 1x/day 12.5 mg 1x/day 25 mg 1x/day
YES
NO
YES
YES
NO
NO YES
YES
Refer to familyplanning
(Section 3.5)
Woman between 15
and 49 years
Suspected RHD andage ≤ 40
Penicillinprophylaxis(Table 9.5)
AscitesAND
K ≤ 3.5 mEq/L ANDCr ≤ 100 µmol/LAND SBP ≥ 90
mmHg
Startspironolactone
(Table 4.15)
Patient with congenital or valvular disease(excluding mitral stenosis) and
diuretic, ACE-inhibitor adjustments made
Atrial fibrillationby ECG
Protocol 4.9
Irregular heart rate
NO
86 chronic care integration for endemic non-communicable diseases
PROTOCOL 4.14 Other Medications for Valvular or Congenital Heart Disease Management (Excluding Mitral Stenosis)
4.11.5 Cardiac Surgery Evaluation
34'*"%A)+$.C'$95'#8"*'$..'-$#)49#*')9'#8)*'+.$**'&6'84$%#'6$)."%4'*8&".5'34'4@$."$#45'37'$'+$%5)&.&A)*#'&%'4E-4%)49+45')9#4%9)*#'<)#8)9'Z'<44P*'#&'Z':&9#8*'&6')9#$P4>'L.#8&"A8'$5@$9+45'4+8&+$%5)&A%$-87')*'9&#'944545'#&'A")54':45)+$.':$9$A4:49#'&6'#84'-$#)49#C')#')*'94+4**$%7'#&'4@$."$#4'#84'
+&:-49*$#45':$7'34'+$95)5$#4*'6&%'*"%A)+$.')9#4%@49#)&9'346&%4'#847'
chapter!4 | heart failure 87
34A)9'#&'54+&:-49*$#4>'L#'#):4*C'#84*4'$%4'#84'34*#'*"%A)+$.'+$95)5$#4*>'Y44'CHAPTER 5'6&%':&%4'54#$).'&9'+$%5)$+'*"%A4%7'4@$."$#)&9>'
4.12 Right-Sided Heart Failure Etiology and Diagnosis
H84'#4%:*'%)A8#2'$95'.46#2*)545'84$%#'6$)."%4'$%4'&6#49'"*45'#&'54*+%)34'$'-$#)49#=*'-%4*49#)9A'*7:-#&:*>'R&*#'4#)&.&A)4*'&6'84$%#'6$)."%4'+$9'%4*".#'6%&:'.46#2*)545'84$%#'6$)."%4'*7:-#&:*'V*"+8'$*'*8&%#94**'&6'3%4$#8'$95'&%#8&-94$XC'$95'-$#)49#*'<)#8'*)A9*'&6'.46#2*)545'84$%#'6$)."%4'<)..'&6#49'8$@4'*)A9*'&6'%)A8#2*)545'84$%#'6$)."%4>',&<4@4%C'-$#)49#*'<)#8')*&.$#45'*7:-#&:*'&6'%)A8#2*)545'84$%#'6$)."%4'V$*+)#4*C'84-$#&:4A$.7C'4.4@$#45'D"A".$%'@49&"*'-%4**"%4'vI\GwC'.&<4%'4E#%4:)#7'454:$X'6$..')9#&'$'5)*#)9+#'+$#4A&%7'&6'5)$A9&*4*>'VY44'TABLE 4.20>X
?9'%4*&"%+42-&&%'*4##)9A*'*"+8'$*';<$95$C')*&.$#45'%)A8#2*)545'84$%#'6$)."%4':&*#'&6#49'%4*".#*'6%&:'+8%&9)+'5)*4$*4*'&6'#84'."9A*'#8$#'8$@4'.45'#&'-".:&9$%7'87-4%#49*)&9'&%'6%&:'5)*4$*4*'&6'#84'-4%)+$%5)":'V*44'TABLE 4.21X>'H"34%+".&*)*')*'37'6$%'#84':&*#'+&::&9'%4$*&9'6&%'+&9*#%)+2#)@4'-4%)+$%5)$.'5)*4$*4')9':&*#'&6'%"%$.'*"32Y$8$%$9'L6%)+$C'$95'$*'*"+8'%4-%4*49#*'$'#%4$#$3.4'+$"*4'&6'84$%#'6$)."%4>
TABLE 4.20 Clinical Presentation of Right-Sided Heart Failure
Symptoms Physical exam findings
Weight gain Elevated JVP
Abdominal swelling Cardiac murmur (depending on cause)
Lower-extremity edema Enlarged or pulsatile liver
Decreased appetite Ascites
Right-upper-quadrant pain Lower-extremity pitting edema
V*"+8'$*'+$%5)&:7&-$#87C'87-4%#49*)@4'84$%#'5)*4$*4C':)#%$.'*#49&*)*C'$95'T%'@$.@".$%'5)*4$*4X'346&%4'+&9*)54%)9A'-"%4'%)A8#2*)545'84$%#'6$)."%4'$*'$'5)$A9&*)*>'L*'<)#8'T%'+$#4A&%)4*'&6'84$%#'6$)."%4C'#84'-%42+)*4'5)$A9&*)*')*'94)#84%'4$*7'9&%'4**49#)$.'#&'#84')9)#)$.':$9$A4:49#'&6'#84'-$#)49#>'b"%'-%&#&+&.'6&%'%)A8#2*)545'84$%#'6$)."%4'#84%46&%4'6&+"*4*'&9'4E+."5)9A'9&92+$%5)$+'+$"*4*'&6'#84'-%4*49#)9A'*7:-#&:*'&6'454:$'
4:-)%)+'#"34%+".&*)*'#%4$#:49#>'
G$#)49#*'<)#8'$*+)#4*'+$"*45'37'.)@4%'6$)."%4'&%'%49$.'6$)."%4'+$9'%4*4:3.4'
5)*#)9A")*8'34#<449'#84*4'-$#)49#*>'U+8&+$%5)&A%$-87')*'4**49#)$.')9'5)664%49#)$#)9A'-$#)49#*'<)#8'%)A8#2*)545'84$%#'6$)."%4'6%&:'#8&*4'<)#8'T%'4#)&.&A)4*'&6'454:$'$95'$*+)#4*>'?9'-$%#)+".$%C'4+8&+$%5)&A%$-87'
88 chronic care integration for endemic non-communicable diseases
+$9'34'84.-6".'$*'$'<$7'#&'4E+."54'84$%#'6$)."%4'$*'$'+$"*4'&6'$*+)#4*>'?6'#84'-$#)49#'8$*'9&':"%:"%*'$95'8$*'$9'49#)%4.7'9&%:$.2$--4$%)9A'3$*)+'4+8&+$%5)&A%$:'V)9+."5)9A'$'9&%:$.')964%)&%'@49$'+$@$'$95'%)A8#'@49#%)+.4XC'#847'$%4'"9.)P4.7'#&'8$@4'$'+$%5)$+'+$"*4'&6'#84)%'-%4*49#)9A'*7:-#&:*'V*44'FIGURE 4.5'$95'FIGURE 4.8X>
)549#)67)9A'#8&*4'-$#)49#*'<8&'$%4'.)P4.7'#&'8$@4'5)*4$*4'+$"*45'37'$+2#)@4'#"34%+".&*)*>'G$#)49#*'<)#8'T%'#7-4*'&6'%)A8#'@49#%)+".$%'6$)."%4'
<)..'34':$)9.7'-$..)$#)@4'$95'<)..':)%%&%'#84'$--%&$+8'#&':45)+$.':$92$A4:49#'&6'-$#)49#*'<)#8'@$.@".$%'$95'T%'+&9A49)#$.'84$%#'5)*4$*4>'
PROTOCOL 4.15'&"#.)94*'$9'$--%&$+8'#&'-$#)49#*'<)#8')*&.$#45'%)A8#2*)545'84$%#'6$)."%4>
TABLE 4.21 Causes of Right-Sided Heart Failure
Cause Notes
Left-sided heart failure Left-sided heart failure is the most common cause of right-sided heart failure. Some common causes include cardiomyopathy, mitral stenosis, and mitral regurgitation
Tricuspid valve abnormalities Tricuspid valve stenosis, tricuspid regurgitation, congenital heart disease
Pulmonary disease Pulmonary TB, severe COPD
Pulmonary hypertension HIV, congenital heart disease (commonly VSD, ASD), other
Constrictive pericarditis Most commonly caused by TB
Endomyocardial fibrosis Cause unknown
NO
YES
Suspected or echocardiographically confirmedisolated right sided heart failure
Assess fluid status, adjust diuretic(Protocol 4.16)
Surgicalcandidate?
Follow-up planning(Section 4.13, Table 4.23)
Surgical planning(Chapter 5)
Assess creatinine, potassium andneed for ACE inhibitor
(Protocol 4.18)
Follow-up and consultationwith a cardiologist to confirm
diagnosis
Assess other medication needs(Protocol 4.19)
Assess for tuberculosis pericarditis(Protocol 4.17)
chapter!4 | heart failure 89
PROTOCOL 4.15 Management of Isolated Right-Sided Heart Failure
4.12.1 Vital Sign AssessmentL*'<)#8'$..'#7-4*'&6'84$%#'6$)."%4C':$9$A4:49#'&6'*"*-4+#45'%)A8#2*)545'84$%#'6$)."%4'34A)9*'<)#8'$9'$**4**:49#'&6'#84'-$#)49#=*'@)#$.'*)A9*'$95'&@4%$..'+&95)#)&9>'G$#)49#*'<)#8'$9'466"*)&9'$95'87-1*)&9'*8&".5'34'-%4*":45'#&'8$@4'#$:-&9$54'$95'*8&".5'34'%464%%45'#&'#84'5)*#%)+#'8&*2-)#$.'6&%'4:4%A49#'-4%)+$%5)&+49#4*)*>'F)P4<)*4C'-$#)49#*'<)#8':$**)@4'$*+)#4*'#8$#')*'+$"*)9A'%4*-)%$#&%7'5)*#%4**'*8&".5'$.*&'34'%464%%45'#&'#84'5)*#%)+#'8&*-)#$.'6&%'-$%$+49#4*)*>
NO YES
Hypo-volemia (1)
Stop alldiuretics,consider
giving fluids
Perform volume assessment(definitions of fluid status di!erent than for
other types of heart failure)
Hyper-volemia
Moderate(3)
Severe(4)
Increasefurosemide
dose(Section 4.7.2)
IV diuresis,paracentesis,
hospitalize
Euvolemia(2)
Suspected or confirmedisolated right-heart failure
On ≤ 80 mgfurosemide
2x/day?
(1) Hypovolemia: Rising creatinine, low blood pressure; may still have significant edema or ascites(2) Euvolemia: Comfortable, able to perform daily activities(3) Hypervolemia, Moderate: Increasing ascites or edema, uncomfortable but able to do basic activities(4) Hypervolemia, Severe: Rapid breathing, unable to walk
Maintatin furosemidedose, consider adding
sprionolactone andACE inhibitor
(Protocol 4.18)
90 chronic care integration for endemic non-communicable diseases
4.12.2 Fluid Status AssessmentH84'94E#'*#4-')9'#84':$9$A4:49#'&6'%)A8#2*)545'84$%#'6$)."%4')*'4@$."$2
-%&6&"95'.4A'454:$'$95'$*+)#4*>'?9':&*#'+$*4*C'#84*4'-$#)49#*'<)..'94@4%'%4$+8'4"@&.4:)$C'$95'$##4:-#)9A'#&'5)"%4*4'#84:'5&<9'#&'$'5%7'<4)A8#'<)..'%4*".#')9')9#%$@$*+".$%'87-&@&.4:)$C'+$"*)9A'%49$.'6$)."%4C'87-Ǭ*)&9C'$95'4.4+#%&.7#4'):3$.$9+4*>'H84'A&$.'*8&".5'34'#&':)9):)^4'#84'-$#)49#=*'5)*+&:6&%#'6%&:'454:$'$95'$35&:)9$.'5)*#49*)&9>'
L*'<)#8'T%'#7-4*'&6'84$%#'6$)."%4C'6"%&*4:)54')*'#84':$)9'#&&.'6&%'+&92SECTION 4.7.2>
Y-)%&9&.$+#&94'*8&".5'34'$5545'#&'$**)*#')9'5)"%4*)*'&6'-$#)49#*'<)#8'9&%:$.'%49$.'6"9+#)&9>'?9'-$#)49#*'<)#8'*4@4%4'5)*+&:6&%#'&%'%4*-)%$#&%7'5)*#%4**'6%&:'$*+)#4*C'-$%$+49#4*)*':$7'34'-4%6&%:45'V*44'SECTION 4.12.4X>
PROTOCOL 4.16 Fluid Status Management in Right-Sided Heart Failure
chapter!4 | heart failure 91
4.12.3 Pericardial Disease()*4$*4*'&6'#84'-4%)+$%5)":'6$..')9#&'#<&':$)9'+$#4A&%)4*W'V/X'-4%)+$%25)$.'466"*)&9*h'$95'VJX'+&9*#%)+#)@4'-4%)+$%5)$.'5)*4$*4>K]'!'&6'#84*4'+&95)#)&9*'+$9'.4$5'#&'84$%#'6$)."%4'37'+$"*)9A'4E#4%9$.'+&:-%4**)&9'&9'
4.12.3.1 Pericardial E#usions2
$..'6&%:*'&6'84$%#'6$)."%4>',&<4@4%C'.$%A4'-4%)+$%5)$.'466"*)&9*'<)#8&"#'
+$9+4%*C'&%'@)%$.')964+#)&9*>'H!')*'#84'+$"*4'&6'.$%A4'-4%)+$%5)$.'466"2*)&9*')9'$3&"#'d1m'&6'#8&*4')964+#45'<)#8',?\C'$95')9'$3&"#'8$.6'&6'#8&*4'9&#')964+#45'<)#8',?\>K]'b9'+84*#'E2%$7'VSp;XC'#84'84$%#'&6#49'$--4$%*'.$%A4'&%'A.&3".$%>'b9'$9'4+8&+$%5)&A%$:C'#84'84$%#')*'*"%%&"9545'37'
FIGURE 4.9X>'?6'.$%A4'49&"A8C'$'-4%)+$%5)$.'466"*)&9'+$9'+$"*4'.)642#8%4$#49)9A'87-1*)&9C'<8)+8')*'P9&<9'$*'+$%5)$+'#$:-&9$54>'
V-4%)+$%5)&+49#4*)*X>
4.12.3.2 Constrictive PericarditisH84'5)*4$*4*'#8$#'+$"*4'$'-4%)+$%5)$.'466"*)&9'+$9'$.*&'.4$5'#&'*+$%%)9A'$95'*#)6649)9A'&6'#84'-4%)+$%5)":>'H8)*')*'P9&<9'$*'+&9*#%)+#)@4'-4%)+$%2
R&*#'-$#)49#*'<)..'-%4*49#'<)#8'*7:-#&:*'&6'%)A8#2*)545'84$%#'6$)."%4C'
6&%'+&9*#%)+#)@4'-4%)+$%5)#)*C'3"#')*'$+#"$..7'%$%4>'S&9*#%)+#)@4'-4%)+$%5)$.'5)*4$*4'*8&".5'34'*"*-4+#45')9'-$#)49#*'<)#8'*)A9*'&6'%)A8#2*)545'84$%#'
2)9A*'&9'4+8&+$%5)&A%$-87'&%'-87*)+$.'4E$:)9$#)&9>
R&*#'+&9*#%)+#)@4'-4%)+$%5)$.'5)*4$*4')9'%"%$.'*"32Y$8$%$9'L6%)+$')*'-%&3$3.7'5"4'#&'H!>'U+8&+$%5)&A%$-87')*'84.-6".')9'#84'5)$A9&*)*'&6'$'-4%)+$%5)$.'466"*)&9'&%'+&9*#%)+#)&9>',&<4@4%C'4@)549+4'&6'H!')964+#)&9'
:&*#'+$*4*>'Sp;'54:&9*#%$#4*'*)A9*'&6'-".:&9$%7'H!')9'&9.7'&942#8)%5'&6'+$*4*C'$95'*-"#":'*:4$%'6&%'$+)526$*#'3$+)..)')*'&6#49'94A$#)@4>K]'(%$)92
$@$).$3.4')9'+&::"9)#723$*45'*4##)9A*>'()$A9&*)*':"*#'#84%46&%4'34'3$*45'&9'+.)9)+$.'-%4*49#$#)&9')9'#84'+&9#4E#'&6'%)*P'6$+#&%*'6&%'H!'$95',?\>
4.12.3.3 Diagnosis and Treatment of Tuberculosis PericarditisG%&:-#')9)#)$#)&9'&6'$9#)2:7+&3$+#4%)$'#%4$#:49#'+$9'34'.)64*$@)9A')9'+$*4*'&6'H!'-4%)+$%5)#)*>'_4'#84%46&%4'*"AA4*#'#8$#'H!')*'#84'-%4*":45'5)$A9&*)*')9'+$*4*'&6'*"*-4+#45'+&9*#%)+#)@4'-4%)+$%5)$.'5)*4$*4>'_4'
92 chronic care integration for endemic non-communicable diseases
%4+&::495'*#$%#)9A'4:-)%)+'#84%$-7')9'#84*4'+$*4*>'L..'-$#)49#*'*#$%#45'&9'H!'#%4$#:49#'*8&".5'8$@4'#8%44'*4#*'&6'*-"#":'+&..4+#45>'L..'-$2#)49#*'*#$%#45'&9'#%4$#:49#'*8&".5'$.*&'34'*449'37'$'+$%5)&.&A)*#'<8&'<)..'54+)54C')9'+&9D"9+#)&9'<)#8'#84')964+#)&"*'5)*4$*4'+.)9)+C'<84#84%'#&'+&9#)9"4'&%'*#&-'#84'$9#)2#"34%+".&*)*':45)+$#)&9*>
H%4$#:49#'&6'-4%)+$%5)$.'H!')*'#84'*$:4'$*'6&%'-".:&9$%7'H!'$95'+&9*)*#*'&6'$'K25%"A'%4A):49'A)@49'&@4%'Z':&9#8*W'J':&9#8*'&6'5$).7')*&9)$^)5C'%)6$:-)9C'-7%$^)9$:)54C'$95'4#8$:3"#&.C'6&..&<45'37'K':&9#8*'&6'5$).7')*&9)$^)5'$95'%)6$:-)9>'H84%4')*'9&'9445'#&'-%&.&9A'#84'+&"%*4'&6'#%4$#:49#>'H84'"*4'&6'+&%#)+&*#4%&)5*')*'+&9#%&@4%*)$.C'3"#')9'*4@4%$.'*#"5)4*C'#84'+&9+&:)#$9#'"*4'&6'-%459)*&94'<)#8'$9#)2H!'#84%$-7'8$*'3449'*8&<9'#&'%45"+4':&%#$.)#7'$95'#84'9445'6&%'*"%A)+$.')9#4%2@49#)&9*>KgCKd'_4'#84%46&%4'%4+&::495'-%4*+%)3)9A'$'*#4%&)5'#$-4%'6&%'-$#)49#*'#%4$#45'6&%'*"*-4+#45'#"34%+".&*)*'-4%)+$%5)#)*'V*44'TABLE 4.22X>'!4+$"*4'%)6$:-)9')9+%4$*4*'#84':4#$3&.)*:'&6'*#4%&)5*C'-%459)*&.&94')*'A)@49'$#'%4.$#)@4.7'8)A8'5&*4*'V$%&"95'/>0':AiPA'-4%'5$7X>
TABLE 4.22 Treatment of Tuberculous Pericarditis in Adults
Medication Dose Schedule
Isoniazid 300 mg once daily 26 weeks
Rifampin 600 mg once daily 26 weeks
Pyrazinamide 20–25 mg/kg once daily (max dose 2 g) 8 weeks
Ethambutol 15–20 mg/kg once daily (max dose 1.6 g) 8 weeks
Prednisolone (example for a 50–55 kg patient)
40 mg twice per day 4 weeks, followed by
20 mg twice per daily 4 weeks, followed by
10 mg twice per day 2 weeks, followed by
5 mg once daily 1 week
YES
NO
NO
YESVery large right
ventricle(Figure 4.8)
Suspected constrictive pericardial disease,diuretic adjustments made
ObtainCXR,
HIV testCXR or historysuggestive of
TB?
Sputum smears,start empiric TB
treatment
Sputum smears,start empiric TB
Treatment
Do not starttreatment
for TB
chapter!4 | heart failure 93
PROTOCOL 4.17 Diagnosis and Treatment of Tuberculosis Pericarditis
4.12.4 Titration of ACE Inhibitors and Spironolactone and Paracentesis
L*'54*+%)345')9'SECTION 4.11.4.1C'*-)%&9&.$+#&94'+$9'34'"*45')9'$55)#)&9'#&'6"%&*4:)54'VF$*)EX'6&%'-$#)49#*'<)#8'$*+)#4*>',&<4@4%C')#'*8&".5'9&#'
5FX>'_849'*-)%&9&.$+#&94')*'-%4*+%)345'$.&9A'<)#8'.)*)9&-%).C'#84'-$#)49#'*8&".5'34':&9)#&%45'6&%'87-4%P$.4:)$'$#'.4$*#'4@4%7'Z':&9#8*>'Y-)%&9&2.$+#&94':$7'34'$'"*46".'$5D"9+#')9'-$#)49#*'<)#8'+8%&9)+$..7'.&<'-&#$*2*)":'*4+&95$%7'#&'6"%&*4:)54'&%'875%&+8.&%)$^)54'"*4>
G$#)49#*'<)#8'#49*4'$*+)#4*':$7'9445'-4%)&5)+'-$%$+49#4*)*'#&'%4.)4@4'$325&:)9$.'5)*+&:6&%#'&%'%4*-)%$#&%7'5)*#%4**>',&<4@4%C'<)#8&"#'+&%%4+#)&9'
2&@4%C'6%4O"49#'-$%$+49#4*)*'-"#*'-$#)49#*'$#'%)*P'6&%'-4%)#&94$.')964+#)&9*'$95'.&**'&6'-%)9C'<8)+8'+$9')9'#"%9'<&%*49'#84'$*+)#4*>
L6#4%'$55)9A'*-)%&9&.$+#&94C'$9'LSU')98)3)#&%':$7'34'$5545'#&'#84'-$2#)49#=*'%4A):49C')6'%49$.'6"9+#)&9'$95'3.&&5'-%4**"%4'-4%:)#>'L*')9'T%'#7-4*'&6'84$%#'6$)."%4C'#84'LSU')98)3)#&%'+$9'84.-'%45"+4'#84'84$%#=*'<&%P.&$5>'?9'$55)#)&9C'-$#)49#*'<)#8'%)A8#2*)545'84$%#'6$)."%4'#495'#&'8$@4'8)A8'.4@4.*'&6'$.5&*#4%&94C'$95'#84'LSU')98)3)#&%C'.)P4'*-)%&9&.$+2#&94C'+$9'+&"9#4%$+#'#8)*>
NO
YES
NOYES
YES
NO
NO
YES
YES
Pregnant,Cr ≥ 200 µmol/L
AND/OR K ≥ 5.5 mEq/L
Able to checkcreatinine and/or potassium?
SBP ≤ 100mmHg
Stop/do notstart ACEinhibitors
K ≥ 6.5mEq/L
ACE inhibitorat goal dose
Maintain ACE inhibitor at current dose,
add spironolactone(Table 4.15)
Isolated right-sidedheart failure, furosemide
adjustments made
IncreaseACE inhibitor
Treat forhyperkalemia
(see Section 6.5)
Maintain or decreaseACE inhibitor AND/OR
spironolactone
94 chronic care integration for endemic non-communicable diseases
PROTOCOL 4.18 ACE-Inhibitor and Spironolactone Titration and Paracentesis for Isolated Right-Sided Heart Failure
4.12.5 Other Medication NeedsG$#)49#*'<)#8')*&.$#45'%)A8#2*)545'84$%#'6$)."%4':$7'*"664%'6%&:'@$%)&"*'+&:&%3)5'+&95)#)&9*C'*&:4'&6'<8)+8':$7'34'%4.$#45'#&'&%'<&%*49'#84)%'84$%#'6$)."%4>'[&%')9*#$9+4C'-$#)49#*'<)#8',?\':$7'54@4.&-'-".:&9$%7'87-4%#49*)&9C'<8)+8'+$9'+$"*4'%)A8#2*)545'84$%#'6$)."%4>'_&:49'<)#8'%)A8#2*)545'84$%#'6$)."%4'*8&".5'$@&)5'34+&:)9A'-%4A9$9#C'$*'-%4A9$9+7'
*8&".5'34'%$#42+&9#%&..45'$95'$9#)+&$A".$#45>
YES
YES
NO
YES
NO
NOYES
Refer to familyplanning
(see Section 3.5)
Woman between 15
and 49 years
Patient with isolated right-sided heart failure;diuretic, ACE inhibitor adjustments made
Atrial fibrillationby ECG
Protocol 4.9
Irregularheart rate
HIVRefer to ID
clinic to startARVs
chapter!4 | heart failure 95
PROTOCOL 4.19 Other Medication Needs in Isolated Right-Sided Heart Failure
4.13 Heart Failure Patient Follow-Up
`&'84$%#'6$)."%4')9#4%@49#)&9'<)..'34'*"++4**6".'<)#8&"#'A&&5'-$#)49#'%4#49#)&9'$95'6&..&<2"->'CHAPTER 3'&"#.)94*'#84'):-&%#$9#'%&.4'+&::"29)#7'84$.#8'<&%P4%*'-.$7')9'#8)*'466&%#>'?9'$55)#)&9C'6%4O"49#':45)+$#)&9'$5D"*#:49#*'%4O")%4'6%4O"49#'+.)9)+'@)*)#*>'[%4O"49+7'&6'@)*)#*'*8&".5'34'
TABLE 4.23'-%&@)54*'#84'A")54'"*45'37'`S('+.)9)+)$9*')9'54#4%:)9)9A'8&<'&6#49'#&'*44'-$#)49#*')9'#84'+.)9)+>'b3@)&"*.7C'+.)9)+)$9*':"*#'%4.7'&9'#84)%'&<9'+.)9)+$.'D"5A:49#'<849'54#4%:)9)9A'8&<'6%4O"49#.7'$'-$#)49#'*8&".5'34'*449>'?9'A494%$.C'<4'49+&"%$A4'+.)9)+)$9*'#&'*44'-$#)49#*':&%4'6%4O"49#.7')6'#847'8$@4'$97'O"4*#)&9*'&%'+&9+4%9*'$3&"#'$'-$#)49#=*'+&95)#)&9'&%':$9$A4:49#>'H8)*'$..&<*'6&%'*:$..4%C':&%4'6%4O"49#'#)#%$#)&9'&6':45)+$#)&9*'$95'6$*#4%'%4+&A9)#)&9'&6'$'54#4%)&%$#)9A'+&95)#)&9>
96 chronic care integration for endemic non-communicable diseases
TABLE 4.23 Clinic Follow-Up Schedule for Heart Failure Patients
Class I or Class II heart failure, euvolemic
Class III or Class IV symptoms, new renal failure, hypervolemic or any other clinical concern
Medication change Return in 2 weeks–1 month Return in 1–2 weeks
No medication change Return in 1–2 months Return in 2 weeks–1 month
?9'%"%$.C'%4*&"%+42-&&%'*4##)9A*'*"+8'$*';<$95$C'#%$@4.'#&'$'+.)9)+'+$9'
5)*#$9+4*>'L*'$'#4:-&%$%7':4$*"%4C'<4'8$@4'%45"+45'3$%%)4%*'#&'+.)9)+'$##495$9+4'37'-%&@)5)9A'#%$@4.'%4):3"%*4:49#'6&%'-$#)49#*'#%$@4.)9A'.&9A'5)*#$9+4*>
4.14 Potassium Management
R$97'&6'#84':45)+$#)&9*'"*45')9'84$%#'6$)."%4':$9$A4:49#'+$9'$664+#'-&#$**)":>'[&%')9*#$9+4C'-&#$**)":'.4@4.*':$7'54+%4$*4'&@4%'#84'+&"%*4'&6'5)"%4*)*>'S&9@4%*4.7C')6'-$#)49#*'8$@4'3$*4.)94'%49$.'57*6"9+#)&9C'-&#$**)":':$7'%)*4'#&'5$9A4%&"*'.4@4.*')6'%49$.'6"9+#)&9'<&%*49*>'G&#$**)":')*'$9'4**49#)$.'4.4+#%&.7#4'#8$#C'<849')9'):3$.$9+4C'+$9'+$"*4'
?9'A494%$.C'-&#$**)":'.4@4.*'<)..'9&#'34+&:4'5$9A4%&"*.7'8)A8'$*'.&9A'$*'+%4$#)9)94')*'9&%:$.>'R$97'6$+).)#)4*'$%4'$3.4'#&'+84+P'+%4$#)9)94'3"#'9&#'-&#$**)":>'L++&%5)9A.7C'<4'8$@4'3$*45'&"%'$.A&%)#8:*'&9'+%4$#)9)94'$.&94>'Y44'SECTION 6.5'6&%'5)*+"**)&9'&6':$9$A4:49#'&6'87-4%P$.4:)$>'
4.15 Arrhythmia Diagnosis and Management
G$#)49#*'<)#8'84$%#'6$)."%4'&6'$97'#7-4'$%4'$#')9+%4$*45'%)*P'&6'8$@)9A'2
:49#')*'@$*#'$95'+&:-.4EC'$95'347&95'#84'*+&-4'&6'#8)*'8$953&&P>',4%4'<4'$):'#&'-%&@)54'$'3$*)+'A")54'6&%'5)*#%)+#2.4@4.'+.)9)+)$9*')9'%4+&A9)#)&9'$95':$9$A4:49#'&6'+&::&9'$%%87#8:)$*>
4.16 Role of Electrocardiography in Rural Rwanda
U.4+#%&+$%5)&A%$:'VUSTX'"*4')*'.):)#45'$#'%"%$.'5)*#%)+#'8&*-)#$.*')9';<$95$>'R$97'5)*#%)+#'8&*-)#$.*'5&'9&#'8$@4'$9'4.4+#%&+$%5)&A%$:':$+8)94C'$95'64<'5)*#%)+#'8&*-)#$.'+.)9)+)$9*'644.'+&:6&%#$3.4')9'#84'"*4'&%')9#4%-%4#$2#)&9'&6'UST*>'H84'A&$.')9';<$95$')*'#&'8$@4'$9'UST':$+8)94'$#'4$+8'5)*#%)+#'8&*-)#$.'$95'#&'-%&@)54'3$*)+'#%$)9)9A')9'UST')9#4%-%4#$#)&9>
chapter!4 | heart failure 97
H84':$)9'"#).)#7'&6'$9'UST')9'%"%$.';<$95$')*'#&'54#4+#'$%%87#8:)$*>'?9'#8)*'*4##)9AC'64<'-$#)49#*'8$@4'+&%&9$%7'$%#4%7'5)*4$*4C'$95'#84'$3).)#7'#&'54#4+#':7&+$%5)$.')96$%+#)&9'&9'UST')*'$'.4**'"*46".'*P)..>'
L.:&*#'$..'$%%87#8:)$*'&++"%'$:&9A'-$#)49#*'<)#8'84$%#'6$)."%4C'-$%2#)+".$%.7'$:&9A'#8&*4'<)#8'$'%45"+45'U['&%':)#%$.'*#49&*)*'$95'$:&9A'
+&::&9'$%%87#8:)$')9'#8)*'*4##)9A>'`S('+.)9)+)$9*'<)#8'9&'-%)&%'UST'#%$)9)9A'+$9'4$*).7'.4$%9'#&')549#)67')#*'+8$%$+#4%)*#)+'UST'-$##4%9>'b#84%'
#%4$#>'a96&%#"9$#4.7C':$97'-$#)49#*'<)#8'@49#%)+".$%'$%%87#8:)$*'94@4%':$P4')#'#&'#84'8&*-)#$.>'G$#)49#*'<)#8'+$%5)&:7&-$#87'$%4'$#'8)A8'%)*P'6&%'#84*4'#7-4*'&6'%87#8:*C'$95'34#$23.&+P4%'"*4'6&..&<)9A'#84'+$%5)&:72&-$#87'-%&#&+&.*'<)..'84.-'%45"+4'#8)*'%)*P>'[&%'#84*4'%4$*&9*C'<4'6&+"*'
<)#8'4*#$3.)*845'84$%#'6$)."%4>'
,4$%#'3.&+P')*'%4.$#)@4.7'%$%4'3"#'-1#)$..7'54$5.7C'$95')#')*'#%4$#$3.4'<)#8'-$+4:$P4%'):-.$9#$#)&9>'
4.16.1 Atrial Fibrillation Diagnosis and Management
+.)9)+)$9*'&3#$)9'$9'UST'&9'$97'-$#)49#'<)#8'$9')%%4A".$%'-".*4'&%'$'@4%7'
#84'UST')9'#84'+.)9)+'&%'$++&:-$97'#84'-$#)49#'#&'#84')9-$#)49#'<$%5'#&'8$@4'#84'UST'-4%6&%:45>'`S('9"%*4*'*8&".5'%4+4)@4'3$*)+'#%$)9)9A')9'UST')9#4%-%4#$#)&9>',&<4@4%C'$'5)*#%)+#'8&*-)#$.'-87*)+)$9'*8&".5'34'$@$).$3.4'#&'84.-'<)#8')9#4%-%4#$#)&9')6'#84%4'$%4'O"4*#)&9*>'H84'P47'UST'
VJX')%%4A".$%.7'*-$+45's;Y'<$@4*'V*44'FIGURE 4.10X>
A
º
A
P waves, regular (normal rhythm)
no P waves, irregular (atrial fibrillation)
P waves
98 chronic care integration for endemic non-communicable diseases
FIGURE 4.10 ECG of Normal Rhythm (top) and Atrial Fibrillation (bottom)
G$#)49#*'<)#8'*)A9*'&6'54+&:-49*$#45'84$%#'6$)."%4'*8&".5'34'$5:)#2
%$#4C'4@49')6')#')*'$*7:-#&:$#)+C'*8&".5'$.*&'*#$7')9'#84'8&*-)#$.'"9#).'
*8&".5'8$@4'#84)%'84$%#'%$#4'.&<4%45')6'-&**)3.4>'F&<4%)9A'#84'84$%#'%$#4'
&"#-"#>'L*'$'A494%$.'%".4C'-$#)49#*'<)#8'$'*7*#&.)+'84$%#'%$#4'&@4%'/11'34$#*'-4%':)9"#4'*8&".5'%4+4)@4'$'#%)$.'&6'34#$23.&+P4%'#%4$#:49#>'()2A&E)9':$7'$.*&'34'A)@49'#&'84.-'*.&<'#84'84$%#'%$#4'$95')*'$'34##4%'+8&)+4')9'-$#)49#*'<)#8'3&%54%.)94'3.&&5'-%4**"%4*'$95i&%'*)A9*'&6'54+&:-492*$#45'84$%#'6$)."%4>'()A&E)9'A494%$..7'#$P4*'"-'#&'$'5$7'#&'#$P4'4664+#>'Y44'TABLE 4.18'6&%'5)A&E)9'5&*)9A>'
G$#)49#*'<)#8'54+&:-49*$#45'84$%#'6$)."%4C'$'.&<'*7*#&.)+'3.&&5'-%4*22
*)&9>'S$%5)&@4%*)&9':$+8)94*'*8&".5'34'$@$).$3.4'$#'$..'5)*#%)+#'8&*-)#$.*>'
22
#)&9'*8&".5'8$@4'$9'4+8&+$%5)&A%$:>'
$*7:-#&:$#)+'$%4'*#)..'$#'8)A8'%)*P'&6'*#%&P4'$95'*8&".5'34'$9#)+&$A"2.$#45>'CHAPTER 5'&"#.)94*')9)#)$#)&9'&6'<$%6$%)9'#84%$-7>'a9.)P4'-$#)49#*'<8&'$.%4$57'8$@4'+.&#*C'#84*4'-$#)49#*'5&'9&#'9445'#&'3%)5A45'<)#8'84-$%)9'#84%$-7'"9#).'#847'%4$+8'$'#84%$-4"#)+'?`;>
NO
YES
YES
YES
YES
NO
NO
NOAdmit to hospital,load with digoxin
(Table 4.18).If unstable, consider
cardioversion
SBP ≥ 100
mmHg
Lower heartrate with
beta-blockerand admit to
hospital
HR ≥ 120bpm
Patient with tachycardia (≥ 120 bpm) AND/ORirregular heart beat
Knownstructural
heartdisease
Initiateanticoagulation(see Chapter 5)
Obtain 12-leadECG to confirmatrial fibrillation
Atrial fibrillation(absence of P waves
and irregularly spacedQRS waves)
Start on aspirin 100 mgdaily, obtain an
echocardiogram
Likely sinus rhythm. If tachycardic, lookfor underlying cause (fever, pain, etc.)
and consider hospital admission
chapter!4 | heart failure 99
PROTOCOL 4.20 Diagnosis and Management of Atrial Fibrillation
4.17 Cardioversion
H84':$)9')95)+$#)&9'6&%'+$%5)&@4%*)&9')*'+$%5)&A49)+'*8&+P')9'#84'*4##)9A'
U@4%7'5)*#%)+#'8&*-)#$.'*8&".5'8$@4'$'+$%5)&@4%*)&9':$+8)94>'G$#)49#*'<8&'$%4'-1#)$..7')9'9445'&6'+$%5)&@4%*)&9'*8&".5'34'$5:)##45'#&'#84'8&*-)#$.'$95':$9$A45'37'#84')9-$#)49#'-87*)+)$9>
NO
YES
NO
NO
YES
YES
NO
YES
YES
YES
NO
NO
YES YES
NO
NO
Pulse ≥ 100 bpm orpauses or extra
beats by palpation?
Patient withpalpitations
Goiter?
Palpitationscurrently?
Fever?
Signs ofdehydration?
ECGavailable?
Check thyroidfunction testsand refer for
ECG
Work upinfection,consider
antibiotics
Murmur,edema,
orthopnea orexertionaldyspnea?
Investigate assuspected heart
failure(see Protocol 4.1)
Reassurepatient, stop any
cardiacmedications.Refer back toprimary care
Atenolol 12.5 mg1x per day or
propranolol 10mg 3x per day
Refer for ECG
No Pwaves orirregularrhythm?
Treat as atrialfibrillation (seeProtocol 4.20)
Look for andtreat underlying
cause
100 chronic care integration for endemic non-communicable diseases
4.18 Palpitations and Somatization
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PROTOCOL 4.21 Palpitations
chapter!4 | heart failure 101
4.19 Palliative Care for Patients with Heart Failure
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102 chronic care integration for endemic non-communicable diseases
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chapter!4 | heart failure 103
Chapter 4!References
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chapter!4 | heart failure 105
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chapter 5Cardiac Surgery Screening, Referral, Anticoagulation, and Postoperative Management
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5.1 History of Cardiac Surgery in Rwanda
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3%
43%54%
Congenital Open rheumatic Other
9
29
132
Visting cardiac surgical teamExternal referralClosed cardiac surgery by local thoracic surgeon
108 chronic care integration for endemic non-communicable diseases
FIGURE 5.1 Indication for Cardiac Surgery between Nov. 2007 and Feb. 2010 (%)
FIGURE 5.2 Source of Cardiac Surgery in Rwanda between Nov. 2007 and Feb. 2010 (n)
chapter!5 | cardiac surgery 109
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110 chronic care integration for endemic non-communicable diseases
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chapter!5 | cardiac surgery 111
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8$*'6&+"*45'&9'*"%A4%7'6&%'#449$A4%*'$95'7&"9A'$5".#*'<)#8'%84":$#)+'@$.@".$%'5)*4$*4>'H8)*'*"%A)+$.'A%&"-'8$*'+&:-.4#45'$9'$99"$.'*"%A)2+$.':)**)&9'6&%'6&"%'+&9*4+"#)@4'74$%*C':&*#'%4+49#.7')9'[43%"$%7'&6'J1//>'H4$:',4$%#'8$*'$.*&'3449'$9'):-&%#$9#'$5@&+$#4'6&%'*#%$#4A)4*'#&'-%4@49#'%84":$#)+'84$%#'5)*4$*4'$95'%84":$#)+'64@4%C')9+."5)9A'*+8&&.23$*45'*+%449)9A>
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S8$)9'&6',&-4'!4.A)":'8$*'$.*&'3%&"A8#'-45)$#%)+')9#4%@49#)&9$.'#4$:*'#&';<$95$>'L.#8&"A8'#84%4')*'9&'+$%5)$+'+$#84#4%)^$#)&9'.$3&%$#&%7')9';<$95$'$#'-%4*49#C'S8$)9'&6',&-4'8$*'3449'$3.4'#&'&-4%$#4'"*)9A'4+8&2
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5.2 Building a National Cardiac Surgery Program
H84%4'$%4'@4%7'64<'9$#)&9$.'+$%5)$+'*"%A)+$.'-%&A%$:*')9'L6%)+$>/Bk/g'H84'+8$..49A4*'&6'4*#$3.)*8)9A'*"+8'+49#4%*'$95'$+8)4@)9A'A&&5'*"%A)+$.'&"#2
/1':)..)&9'&%':&%4'-4&-.4'+$9'4$*).7'D"*#)67'#84'9445'6&%'$#'.4$*#'&94'.&2+$.'+49#4%'#&'-4%6&%:'B11'&%':&%4'*"%A4%)4*'-4%'74$%>'_4'8$@4'4*#):$#45'#8$#'*"+8'+49#4%*'+&".5'-%&@)54'@$.@".$%'%4-.$+4:49#*'6&%'"954%'r0111'-4%'+$*4'V*44'APPENDIX BX>'G%&A%$:*'#8$#'&-4%$#4'&9'B11'&%':&%4'+$*4*'-4%'74$%':"*#'34'$3.4'#&'%4.7'&9'$'*#%&9A'*7*#4:'&6'+8%&9)+'+$%4'+$-$3.4'&6'$9#)+&$A".$#)&9':&9)#&%)9A'$#'5)*#%)+#28&*-)#$.'.4@4.>'H84'6&..&<)9A'
112 chronic care integration for endemic non-communicable diseases
5.2.1 Cardiac Surgical ReferralS$%5)$+'*"%A)+$.'-%&A%$:*'9445'#&'8$@4'$++4**'#&'$'.$%A4'$95'9$#)&9$..7')9+."*)@4'*4#'&6'-1#)$.'+$%5)$+'*"%A)+$.'+$95)5$#4*>'b94'+8$..49A4'6&%'+$%5)$+'*"%A)+$.'-%&A%$:*')*'49*"%)9A'#8$#'#84'-&&%'.)@)9A')9'%"%$.'+&:2:"9)#)4*C'.&+$#45'6$%'6%&:'#84'+$-)#$.C'8$@4'4O"$.'$++4**'#&'%464%%$.'6&%'+$%5)$+'*"%A4%7>'H%$5)#)&9$..7')9';<$95$C'$*')9':$97'+&"9#%)4*C'+$%5)$+'*"%A4%7'-%&A%$:*'8$@4'%4.)45'"-&9'$'+&:3)9$#)&9'&6'4E)*#)9A'%464%%$.'*7*#4:*'$95')9#4%:)##49#'+$%5)$+'*"%A)+$.'*+%449)9A'+$:-*>'`$#)&9$.'*+$.42"-'&6'`S('+.)9)+*'$#'5)*#%)+#'8&*-)#$.*'<)..'-.$7'$'+%"+)$.'%&.4')9'4E-$95)9A'$95'49%)+8)9A'#84'-&&.'&6'-&**)3.4'+$%5)$+'*"%A)+$.'+$95)25$#4*'$@$).$3.4'6&%'4@$."$#)&9'37'*-4+)$.)*#*'$#'#84'a9)@4%*)#7'H4$+8)9A'
54*+%)34'8&<'`S('+.)9)+*'6445')9#&'#84'+$%5)$+'*"%A)+$.'*4.4+#)&9'*7*#4:>
b9+4'$'5)*#%)+#'`S('+.)9)+'*7*#4:')*')9'-.$+4C'84$%#'6$)."%4'+$*4*'$%4'CHAPTER 4X>'
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b9+4'#84'+$%5)&.&A)*#'54#4%:)94*'#8$#'$'-$#)49#')*'$'*")#$3.4'*"%A)+$.'+$95)5$#4C'84'&%'*84'$55*'#84:'#&'$'9$#)&9$.'+$%5)$+'*"%A)+$.'<$)#)9A'.)*#>'G%)&%'#&'4$+8'+$%5)$+'*"%A)+$.':)**)&9C'@)*)#)9A'#4$:*'+$9'%4@)4<'#8)*'.)*#'$*'-$%#'&6'#84)%')9)#)$.'-$#)49#'+$*4'*4.4+#)&9>'
TABLE 5.1'*8&<*'#84'#7-)+$.'4@$."$#)&9*'%4O"4*#45'37'+$%5)$+'*"%A)+$.'#4$:*'-%)&%'#&'*"%A4%7>
chapter!5 | cardiac surgery 113
TABLE 5.1 Typical Preoperative Evaluation for Cardiac Surgery
History
Physical examination
Laboratory studies
Imaging
5.2.2 Principles of Case Selection?#'8$*'3449'#84'&3*4%@$#)&9'&6'@)*)#)9A'$5".#'+$%5)$+'*"%A)+$.'#4$:*')9';<$95$'#8$#'-$#)49#*'<)#8'%84":$#)+'@$.@".$%'5)*4$*4C'$95'-$%#)+".$%.7'#84'-&&%4*#'$95'#8&*4'6%&:'%"%$.'$%4$*C'-%4*49#'.$#4')9'#84)%'+.)9)+$.'+&"%*4>'!7'#8)*'#):4C'#84*4'-$#)49#*'$%4'$.%4$57'4E-4%)49+)9A'`c,L'S.$**'???'$95'?\'84$%#'6$)."%4'*7:-#&:*C'<)#8')9@&.@4:49#'&6'#<&C'$95'*&:4#):4*'#8%44C'+$%5)$+'@$.@4*>
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?9';<$95$C'+$%5)$+'*"%A)+$.'+$*4'*4.4+#)&9')*'+&&%5)9$#45'9$#)&9$..7'37'#84'+$%5)$+'*"%A4%7'-%&A%$:'5)%4+#&%'<)#8')9-"#'6%&:'$..'+$%5)&.&A)*#*>',4%4'<4'54*+%)34'*&:4'-%)9+)-.4*'&6'+$*4'*4.4+#)&9')9'$'*4##)9A'<84%4'
114 chronic care integration for endemic non-communicable diseases
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5.3 Common Procedures for Cardiac Valves
`S('9"%*4*'$95'A494%$.)*#'-87*)+)$9*'<&%P)9A'$#'5)*#%)+#'8&*-)#$.*'9445'#&'"954%*#$95'*&:4'&6'#84'3$*)+*'$3&"#'+$%5)$+'@$.@".$%'*"%A4%7>/d'H84'6&..&<2"-')**"4*'6&%'-$#)49#*'6&..&<)9A'+$%5)$+'*"%A4%7'54-495C')9'-$%#C'&9'#84'9$#"%4'&6'#84'*"%A4%7'#847'8$@4'"954%A&94>
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chapter!5 | cardiac surgery 115
L++4**'#&'84$%#'*"%A4%7')9';<$95$'$95'*"%%&"95)9A'+&"9#%)4*')*'.):)#45>'T)@49'#84'6$+#'#8$#'%4&-4%$#)@4'84$%#'*"%A4%7')*'9&#'.)P4.7'#&'34'$'-%)&%)#7')9'#84'94$%'6"#"%4C'4E-4%)49+45'@)*)#)9A'#4$:*'$%4'&-#)9A':&%4'&6#49'6&%'@$.@4'%4-.$+4:49#'#84%$-7'6&%'-$#)49#*'<)#8'%84":$#)+'84$%#'5)*4$*4>
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5.3.1 Mitral or Tricuspid Valve RepairY&:4'@$.@".$%'5$:$A4')*':).5'49&"A8'#&'34'%4-$)%45>'H84':$)9'$5@$9#$A4'
)9#$+#>'H8)*'+&9#%)3"#4*'#&'34##4%'6"9+#)&9'&6'#84'$**&+)$#45'@49#%)+.4>'H84'%)*P'&6'%4&-4%$#)&9'5"4'#&'6$)."%4'&6'#84'%4-$)%'-%&3$3.7'6$..*'*&:4<84%4'34#<449'#84'%)*P*'&6'6$)."%4')9'3)&-%&*#84#)+'$95':4+8$9)+$.'@$.@4*>J1
[&%'-$#)49#*'<)#8':)#%$.'*#49&*)*'5"4'#&'6"*)&9'&6'#84'$9#4%)&%'$95'-&*#42
)*'+$..45'$'5$--2**.#$,$-0'V*44'TABLE 5.2X>'?9'-$#)49#*'<)#8'%4A"%A)#$9#':)#%$.'@$.@4'5)*4$*4C'$':4#$.'%)9A'+$9'34'"*45'#&'*.)A8#.7'9$%%&<'#84'@$.@4>'H84'%)9A')*'-.$+45'$%&"95'#84'&"#4%'45A4'&6'#84'@$.@4'V$.*&'+$..45'#84'$99"."*X>'H8)*'-%&+45"%4')*'+$..45'$'#24>+(44./$1/(*,0>'?9'$55)#)&9C'*&:4'-$#)49#*':$7'$.*&'9445'#&'8$@4'-$%#'&6'#84)%'@$.@4'+"#'$<$7C'&%'
TABLE 5.2 Types of Valve Repairs
Ring annuloplasty Commissurotomy
Indication Mitral or tricuspid regurgitation Mitral or tricuspid stenosis
Anticoagulation Yes, with aspirin Yes, with aspirin
116 chronic care integration for endemic non-communicable diseases
5.3.2 Percutaneous ProceduresL':)9):$..7')9@$*)@4'-%&+45"%4'+$9'&-49'"-'*#49&#)+'@$.@4*'$95'+$9'+.&*4'+4%#$)9'+&9A49)#$.'84$%#'.4*)&9*>'L'*:$..'+$#84#4%')*'-.$+45'#8%&"A8'#84'A%&)9'V)9#&'#84'64:&%$.'$%#4%7'&%'@4)9X'$95')*'-$**45'"-<$%5'#&<$%5'#84'84$%#>'Y:$..'+&%%4+#)@4'54@)+4*'+$9'34'-$**45'#8%&"A8'#84*4'+$#824#4%*'#&'%4-$)%'#84'5464+#>'?6'#8)*'#7-4'&6'-%&+45"%4'+$9'34'5&94C')#')*'-%464%%45C'*)9+4')#'+$%%)4*'#84'*:$..4*#'%)*P>'
;<$95$'+"%%49#.7'5&4*'9&#'8$@4'$'+$%5)$+'+$#84#4%)^$#)&9'.$3&%$#&%7C'3"#')#')*'-&**)3.4'#&'-4%6&%:'*&:4'+&9A49)#$.'-%&+45"%4*'<)#8'4+8&+$%2
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4$%.7')9'#84'54@4.&-:49#'&6'$'+$%5)$+'*"%A)+$.'-%&A%$:'$%4'V/X'#84'9445'6&%'5)$A9&*#)+'+$#84#4%)^$#)&9C'$95'VJX'54.)@4%7'&6'.&<2%)*P'-%&+45"%4*'6&%'+&9A49)#$.'84$%#'5)*4$*4>
5.3.3 Mechanical Valves
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chapter!5 | cardiac surgery 117
5.3.4 Bioprosthetic Valves!)&-%&*#84#)+'@$.@4*'$%4':$54'6%&:'.)@)9A'#)**"4'V6%&:'$'+&<C'-)AC'&%'8":$9X'$95'$%4'*8$-45'#&'%4*4:3.4'$'9&%:$.'84$%#'@$.@4>'Y)9+4'#847'$%4':$54'&6'.)@)9A'#)**"4C'#84'%)*P'&6'#8%&:3&*)*')*'A%4$#.7'%45"+45C'$95'&9.7'$*-)%)9'V/11':AC'/Ei5$7X')*'944545>',&<4@4%C'9&%:$.'84$%#'6"9+#)&9'+$9'5$:$A4'#84*4'@$.@4*>'H847'%$%4.7'.$*#':&%4'#8$9'/1'74$%*C'$95'*&:42#):4*':"+8'.4**>JJ'VY44'TABLE 5.3>X
!)&-%&*#84#)+'@$.@4*'$%4'A&&5'6&%'#84'6&..&<)9A'#7-4*'&6'-$#)49#*W
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TABLE 5.3 Types of Replacement Heart Valves
Bioprosthetic Mechanical
Anticoagulation Aspirin Warfarin
Longevity ~10 years, probably less ~20 years, potentially life-long
Endocarditis risk Increased Increased
Used in
future pregnancies desire more children
5.4 Early Post-Operative Evaluation (First 3 Months)
?9'$55)#)&9'#&'#84)%'%4A".$%'@)*)#*'#&'$'+8%&9)+'+$%4'+.)9)+C'-&*#2+$%5)$+'*"%A4%7'-$#)49#*'*8&".5'34'*449'37'$'+$%5)&.&A)*#'$#'.4$*#'K'#):4*')9'#84'
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118 chronic care integration for endemic non-communicable diseases
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5.4.1 Heart Failure
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5.4.2 Sternal Wound Infection and DehiscenceH&'$++4**'#84'84$%#'6&%'*"%A4%7C'#84'*#4%9":':"*#'34'+"#>'L#'#84'495'&6'#84'-%&+45"%4C'#84'*#4%9":')*'%4-$)%45'"*)9A'<)%4*>'b9'&++$*)&9C'*&:4'&6'#84*4'<)%4*':$7'*4-$%$#4C'+$"*)9A'548)*+49+4'$95')9*#$3).)#7'&6'#84'*#4%9":>'?6'#8)*'&++"%*C'-$#)49#*'$%4'$#'%)*P'6&%')964+#)&9*'&6'#84'<&"95'$95'&6'#84'544-4%'*#%"+#"%4*'&6'#84'84$%#>'H8)*')*'$9'4:4%A49+7h'-$#)49#*'9445')::45)$#4'#%4$#:49#'<)#8'$9#)3)&#)+*>'L#'4$+8'&6'#84'4$%.7'@)*)#*'
chapter!5 | cardiac surgery 119
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5.4.3 Pericardial Tamponade("%)9A'+$%5)$+'*"%A4%7C'#84'-4%)+$%5)":')*'&-4945>'R&*#'-$#)49#*'<)..'8$@4'$'*:$..'-4%)+$%5)$.'466"*)&9'#8$#'%4*&.@4*'$6#4%'B'#&'Z':&9#8*>'?9'
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2+)9')*'$9'$.#4%9$#)@4')9'#8&*4'<)#8'$'-49)+)..)9'$..4%A7W'Z11':A')9'$5".#*C'J1':AiPA')9'+8).5%49'V:$E):":'Z11':AX>
5.4.5 Atrial ArrhythmiasL6#4%'+$%5)$+'*"%A4%7C'-$#)49#*'$%4'$#'8)A8'%)*P'6&%'54@4.&-)9A'$#%)$.'
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120 chronic care integration for endemic non-communicable diseases
5.5 Ongoing Monitoring of the Post-Operative Patient
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5.5.1 Fever in Patients with Prosthetic Heart ValvesG$#)49#*'<)#8'$97'#7-4'&6'-%&*#84#)+'84$%#'@$.@4'%4:$)9'$#'%)*P'6&%'@$.@4')964+#)&9*'V495&+$%5)#)*X>'H84'-$#)49#=*'#4:-4%$#"%4'*8&".5'34'+84+P45'$#'4$+8'6&..&<2"-'@)*)#'$95'#84'-$#)49#'*8&".5'34'$*P45'$3&"#'*"3D4+#)@4'
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-4%)-84%$.'@$*&-%4**&%*'*"+8'$*'5&-$:)94')6'944545X'$95'#849'#%$9*264%%45'#&'#84'+$-)#$.'6&%'%464%%$.'+49#4%k.4@4.'+$%4>'Y"+8'#%$9*64%*'*8&".5'34'+&::"9)+$#45'-%&:-#.7'#&'#84'9$#)&9$.'+$%5)$+'*"%A4%7'+&&%5)9$#&%'$95'#&'#84'+$%5)&.&A)*#'6&..&<)9A'#84'-$#)49#>'
L6#4%'3.&&5'+".#"%4*'$%4'5%$<9C'4:-)%)+'$9#)3)&#)+*'*8&".5'34'*#$%#45>'?9#%$@49&"*'@$9+&:7+)9')*'#84'-%464%%45'4:-)%)+'#%4$#:49#C'3"#')6'#8)*'5%"A')*'9&#'$@$).$3.4C'#849'#84'+&:3)9$#)&9'&6'+.&E$+)..)9'$95'+46#%)$E&94')*'$9'$.#4%9$#)@4'V*44'TABLE 5.4X>
chapter!5 | cardiac surgery 121
TABLE 5.4 Empiric Antibiotic Treatments for Endocarditis
Antibiotic Indication Adult dose Pediatrics dose E"ect on warfarin
Vancomycin Empiric endocarditis therapy, methicillin-resistant Staphylococcus aureus, Staphylococcus epidermidis, enterococcus
1 gm 2x/d 10 mg/kg 4x/d No e#ect
OR (Combination therapy with cloxacillin + ceftriaxone or penicillin G)
Cloxacillin Empiric endocarditis therapy, methicillin-sensitive Staphylococcus aureus, empiric treatment of cellulitis in patients with prosthetic heart valves
2 gm daily IV 50 mg/kg every 6 hours IV
No e#ect
Ceftriaxone Empiric endocarditis therapy, Streptococcus viridans, empiric treatment of urinary tract infection, pneumonia in patients with prosthetic heart valve
2 gm daily IV or IM
100 mg/kg/d IV or IM (maximum 2 gm)
Decreases warfarin e#ect
Penicillin G Empiric endocarditis therapy, Streptococcus viridans
4.5 million units IV 4x/d
50,000 U/kg IV 4x/d
No e#ect
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Patient with prosthetic
valve and fever (T ≥ 38° C or
100.4° F)
1. Heart failureOR
2. BP ≤ 80/40 mmHgOR
3. Other signs of sepsis or endocarditis
(e.g., new murmur)
1. History and physical examinationFollowed by laboratory evaluation as needed:1. Urinalysis2. Peripheral blood smear for malaria3. Chest x-ray
Clear source of fever?
Improvement within 48 hours
1. Hospitalize at district level2. Treat infection empirically
Continue management with careful attention to:1. Warfarin management (if relevant)2. In-hospital risks such as IV-line
and urinary catheter infections3. Venous thromboembolism
No fever within 14 days from admission
Weekly follow-up at NCD clinic for
1 month
1. Hospitalize at district hospital2. Stabilize blood pressure with fluids3. Draw two sets of blood cultures4. Start empiric antibiotics for endocarditis (Table 5.4)5. Transfer as quickly as possible to referral hospital for admission, blood culture, echocardiography, and specific antibiotic therapy
YES
NO
YES
NO
NO
YES NO
YES
122 chronic care integration for endemic non-communicable diseases
PROTOCOL 5.1 Management of Fever in Patients with Prosthetic Heart Valves
_4'5&'9&#'$55%4**'#84'.&9A2#4%:'#%4$#:49#'&6'495&+$%5)#)*')9'#8)*'A")54>'b94':$D&%')**"4')9'#84'#%4$#:49#'&6'-%&*#84#)+2@$.@4'495&+$%5)#)*')*'#8$#')#'"*"$..7')9@&.@4*')9#%$@49&"*'$9#)3)&#)+*'6&%'$#'.4$*#'Z'<44P*'V*44'TABLE 5.5X>'b%$.'$9#)3)&#)+*'$.&94'$%4'9&#'$9'$++4-#$3.4'$.#4%9$#)@4'#&')9#%$@429&"*'#%4$#:49#C'$95'#84'9445'#&'6%4O"49#.7'+8$9A4'-4%)-84%$.')9#%$@429&"*'+$#84#4%*'+$9'34'$'-%&3.4:>'U66&%#*'*8&".5'34':$54'#&')9#%&5"+4'*P)..*')9':)5.)94')9#%$@49&"*'+$#84#4%'-.$+4:49#'$95'+$%4'$#'#84'5)*#%)+#'8&*-)#$.'.4@4.>
L9'$55)#)&9$.'+&9*)54%$#)&9')*'#8$#':$97'$9#)3)&#)+*':&5)67'#84'4664+#'&6'<$%6$%)9'V*44'TABLE 5.6X>'?9'-$#)49#*'#$P)9A'<$%6$%)9C'#84')9#4%9$#)&9$.'
chapter!5 | cardiac surgery 123
9&%:$.)^45'%$#)&'V?`;X'*8&".5'$.*&'34'6&..&<45'+.&*4.7'5"%)9A'$9#)3)&#)+'#%4$#:49#>
[)9$..7C'=,(1&0/$5$55.*+(.#'.*'495&+$%5)#)*')*'-$%#)+".$%.7'$AA%4**)@4')9'-%&*#84#)+'84$%#'@$.@4*'$95':$7'4@49'%4O")%4'%4&-4%$#)&9>'L..'495&+$%25)#)*'+$*4*'*8&".5'34':$9$A45'@4%7'+.&*4.7'<)#8'#84'5)%4+#&%'&6'#84'9$2#)&9$.'+$%5)$+'*"%A)+$.'-%&A%$:')9'5)*+"**)&9'<)#8'#84'9$#)&9$.'+$%5)$+'*"%A)+$.'+&::"9)#7>
TABLE 5.5 Some Organism-Specific Treatments for Prosthetic Valve Endocarditis
Antibiotic Duration of therapy Adult dose Pediatrics dose E"ect on warfarin
Staphylococcus aureus (methicillin-resistant): combination therapy
Vancomycin 6 weeks 1 gm 2x/d 10 mg/kg 4x/d No e#ect
Gentamycin 2 weeks 3 mg/kg/d IV or IM divided into 3 doses
50 mg/kg every 6 hours IV
No e#ect
Rifampin 6 weeks 300 mg orally daily 7 mg/kg orally 3x/d Markedly decreases warfarin e#ect
Staphylococcus aureus (methicillin-sensitive): combination therapy
Cloxacillin 6 weeks 2 gm daily IV 50 mg/kg every 6 hours IV
No e#ect
Gentamycin 2 weeks 3 mg/kg/day IV or IM divided into 3 doses
50 mg/kg every 6 hours IV
No e#ect
Rifampin 6 weeks 300 mg orally daily 7 mg/kg orally 3x/d Markedly decreases warfarin e#ect
Streptococcus viridans (ceftriaxone or penicillin G)
Ceftriaxone 6 weeks 2 grams daily IV or IM 100 mg/kg/d IV or IM (maximum 2 gm)
Decreases warfarin e#ect
Penicillin G 6 weeks 4.5 million units IV 4x/d
50,000 U/kg IV 4x/d No e#ect
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124 chronic care integration for endemic non-communicable diseases
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5.6 Penicillin Prophylaxis for Patients with Surgically Corrected Rheumatic Valvular Disease
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5.7 Methods of Anticoagulation and Indications
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,&<4@4%C'-$#)49#*'$#'8)A84%'%)*P'&6'*#%&P4C'*"+8'$*'#8&*4'<)#8'$'P9&<9'#8%&:3"*'&%'$':4+8$9)+$.'84$%#'@$.@4C'%4O")%4'$'A%4$#4%'54A%44'&6'
chapter!5 | cardiac surgery 125
$9#)+&$A".$#)&9>'H8)*')*'$+8)4@45'<)#8'<$%6$%)9C'<8)+8')98)3)#*'*79#84*)*'&6'*4@4%$.'3.&&5'+&$A".$#)&9'-%)9*>'_$%6$%)9')*'$'#%)+P7'5%"A>'R4#$3&2.)*:'@$%)4*'A%4$#.7'6%&:'-4%*&9'#&'-4%*&9'$95'<)#8)9'#84'*$:4'-$#)49#'6%&:'5$7'#&'5$7C'$95'4@49'8&"%'#&'8&"%C'54-495)9A'&9')9#4%$+#)&9*'<)#8'6&&5'$95':45)+$#)&9*>'TABLE 5.6'.)*#*'*&:4'&6'#84'+&::&9':45)+$#)&9*'#8$#')9#4%$+#'<)#8'<$%6$%)9>
TABLE 5.6 Common Drug Interactions with Warfarin
Drug E"ect on INR
Co-trimoxazole Increase
Metronidazole Increase
Ciprofloxacin Increase
Cimetidine Increase
Rifampin Decrease
Antiretroviral drugs Increase or decrease
Alcohol Increase or decrease
R&%4&@4%C'<$%6$%)9'#$P4*'*4@4%$.'5$7*'#&'$+8)4@4'$'#84%$-4"#)+'.4@4.'&6'$9#)+&$A".$#)&9>'Y"3+"#$94&"*'49&E$-$%)9'VS.4E$94X'&%'*"3+"#$94&"*'"96%$+#)&9$#45'84-$%)9')*'"*45')9'-$#)49#*'$#'$'@4%7'8)A8'%)*P'&6'*#%&P4'<8&'%4O")%4'$55)#)&9$.'$9#)+&$A".$#)&9'V$'N3%)5A4QX'"9#).'#84'<$%6$%)9'#$P4*'4664+#>
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S&::&9')95)+$#)&9*'6&%'$9#)+&$A".$#)&9')9'&"%'+.)9)+*'$95'5)*#%)+#'8&*-)22
*)*C'.46#'@49#%)+".$%'#8%&:3"*C'$#%)$.'#8%&:3"*C'544-'@49&"*'#8%&:3&*)*C'$95'-".:&9$%7'4:3&.)*:>'H%4$#:49#'$):*'#&'-%4@49#'*#%&P4'$95'T%'4:3&.)+'5)*4$*4'<8).4':)9):)^)9A'#84'%)*P*'&6'3.445)9A>'TABLE 5.7'.)*#*'&"%')95)+$#)&9*'6&%'$9#)+&$A".$#)&9'$95'#84'$A49#*'<4'"*4>
126 chronic care integration for endemic non-communicable diseases
TABLE 5.7 Anticoagulation Agents and Indications
Indications Warfarin or aspirin? Heparin bridge?
Goal INR Duration of therapy
Heart failure and atrial fibrillation
Peripartum cardiomyopathy Aspirin N/A N/A Lifelong
Mitral stenosis in sinus rhythm Aspirin N/A N/A Lifelong
Mitral stenosis with signs of prior stroke Warfarin No 2.0–2.5 Lifelong
Atrial fibrillation (without heart failure) Aspirin N/A N/A Lifelong
Atrial fibrillation (with heart failure) Warfarin No 2.0–2.5 Lifelong
Prosthetic valves
Bioprosthetic tricuspid valve Warfarin for the first 3 months, then aspirin
Yes 2.5–3.0 Lifelong
Other bioprosthetic valves (not tricuspid) Aspirin N/A N/A Lifelong
Mechanical aortic valve Warfarin Yes 2.5–3.0 Lifelong
Mechanical mitral valve Warfarin Yes 3.0–3.5 Lifelong
Mechanical tricuspid valve Warfarin Yes 3.0–3.5 Lifelong
Thrombus
Ventricular thrombosis Warfarin Yes 2.0–2.5 6 months
Deep-vein thrombosis Warfarin Yes 2.0–2.5 3 months
Pulmonary embolism Warfarin Yes 2.0-2.5 6 months
5.8 Initiating Warfarin Therapy
G%&#&+&.*')9'-%4@)&"*'+8$-#4%*'8$@4')95)+$#45'<849'$9#)+&$A".$#)&9'
5.8.1 Contraindications to Warfarin Therapy!46&%4'*#$%#)9A'<$%6$%)9'#84%$-7C'-$#)49#*'*8&".5'34'$**4**45'6&%'%4.$2#)@4'+&9#%$)95)+$#)&9*'#&'<$%6$%)9'#84%$-7>
_$%6$%)9')9'-%4A9$9+7'+$9'+$"*4'*4%)&"*'3)%#8'5464+#*'$*'<4..'$*'64#$.'
<)#8'#84'<&:$9>'?9'*&:4'+$*4*C'*"+8'$*'#84'-%4*49+4'&6'$':4+8$9)+$.'@$.@4C'#84'%)*P'#&'#84':T%'&6'9&#'#$P)9A'<$%6$%)9'<)..'.)P4.7'&"#<4)A8'
&6'$9'4:3&.)+'4@49#':$7'34'544:45'.&<'49&"A8'#8$#'#84'<&:$9'<)..'+8&&*4'9&#'#&'#$P4'<$%6$%)9'5"%)9A'#84'-%4A9$9+7>
chapter!5 | cardiac surgery 127
;4+49#C'*4%)&"*'3.445)9A')*'$9T%'%4.$#)@4'+&9#%$)95)+$#)&9>'LA$)9C'#8)*'*8&".5'34'<4)A845'$A$)9*#'#84'%)*P'&6'4:3&.)+'4@49#*')9'54+)5)9A'<84#84%'&%'9&#'#&'*#$%#'<$%6$%)9>
G$#)49#*'*8&".5'$.*&'34'$**4**45'6&%'*)A9*'&6'.)@4%'5)*4$*4>'L'-$#)49#'<)#8'$'.$%A4C'-$.-$3.4'.)@4%'&9'4E$:'*8&".5'8$@4'$9'?`;'+84+P45'-%)&%'#&')9)#)2$#)9A'<$%6$%)9'#84%$-7>'_$%6$%)9'*8&".5'*#)..'34'A)@49')6'#84'?`;')*'34.&<'#84'A&$.'%$9A4C'3"#'#84%$-7'*8&".5'34'*#$%#45'$#'8$.6'#84'9&%:$.'5&*4>'
5.8.2 Monitoring Warfarin?9':$97'.&<2)9+&:4'*4##)9A*C'#84'+&*#*'&6'<$%6$%)9'$95'&6':&9)#&%)9A'54@)+4*'$%4'*449'$*'$9')9*"%:&"9#$3.4'3$%%)4%'#&'$9#)+&$A".$#)&9>'?9'&"%'4E-4%)49+4C')9@4*#:49#')9'#8)*')9#4%@49#)&9')*'+&*#24664+#)@4'$95'.4**'5$9A4%&"*'#8$9'A494%$..7'-4%+4)@45>'G$#)49#*'$%4'"*"$..7'@4%7'@)A).$9#'$3&"#'+84+P)9A'#84)%'&<9'?`;>'G%&-4%.7'#%$)945'+&::"9)#7'84$.#8'<&%P4%*'$%4'$'A%4$#'$)5')9'84.-)9A'#&':&9)#&%'$95'#)#%$#4'<$%6$%)9'5&*4*>'
6&%'#84)%'%)*P'&6'*#%&P4'&%'T%'4:3&.)+'4@49#*>'G$#)49#*'$#'.&<'%)*P'&6'
8$@4'<$%6$%)9')9)#)$#45')9'#84'&"#-$#)49#'*4##)9A'<)#8'+.&*4'6&..&<2"->
TABLE 5.8'.)*#*'%4+&::49545'5&*)9A'6&%'&"#-$#)49#')9)#)$#)&9'&6'<$%6$%)9>'`'#8$#'#8)*'5&*)9A')*'.&<4%'#8$9'#7-)+$..7'"*45')9'*4##)9A*'<)#8':&%4')9#49*)@4':&9)#&%)9A>
TABLE 5.8 Initial Outpatient Warfarin Dosing
Patient age Initial dose
Adults 2.5 mg/day
Children (5–40 kg) 1 mg/day
G$#)49#*'$#'8)A8'%)*P'&6'4:3&.)+'4@49#*')9+."54'#8&*4'<)#8':4+8$9)+$.'@$.@4*'$95'#8&*4'<)#8'$9'$+#)@4'+.&#')9'#84'84$%#'&%'#84'544-'@4)9*'&6'#84'.4A*>'L97'-$#)49#'<8&')*'$#'@4%7'8)A8'%)*P'&6'#8%&:3&*)*'$95'<8&'#84%46&%4'%4O")%4*'$'84-$%)9'3%)5A4':"*#'34'*#$%#45'&9'<$%6$%)9')9'#84'8&*-)#$.>'a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
2.5 mg/day
YESPatient with
indication forwarfarin
Requires heparinbridge because high risk
of embolic events?(Table 5.9)
Patientpregnant?
NO
Start warfarin therapy:Adults: 2.5 mg/day
Chidren 5–40 kg: 1 mg/day
If INR ≥ goal INR do not start warfarinIf INR ≤ goal INR, start warfarin at half
normal dose (Table 5.10)
Reconsider indications forwarfarin. Consider aspirin
as an alternativeYES
Palpable liver on exam or known
liver failure?
Check INR prior to initiating
warfarin therapyElevated
INR?
Assign community health worker
Follow-up in one weekat the district hospital
NO
NO YES
YES
1. Admit to district hospital2. Start warfarin (Table 5.8)3. Start a medication to bridge
the patient (Table 5.9)
128 chronic care integration for endemic non-communicable diseases
?6'#84'<$%6$%)9')*'5)*+&9#)9"45'$95'#84%$-7'8$*'#&'34'%42)9)#)$#45'5"4'#&'$9'?`;'34.&<'/>0C')#')*'34*#'#&'8&*-)#$.)^4'#84'-$#)49#'$95'$5:)9)*#4%'$9T%'$A49#'"9#).'#84'?`;'%)*4*'8)A84%'#8$9'J>1>
PROTOCOL 5.2 Initiating Warfarin Therapy
TABLE 5.9 Therapies For Bridging Anticoagulation
Medication Dosing
Enoxaparin (Clexane) 1 mg/kg twice per day
Heparin (subcutaneous)27,28 Adult: 15,000 units 2x/dChild: 250 units/kg 2x/d
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chapter!5 | cardiac surgery 129
5.9 Titrating Warfarin Therapy
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130 chronic care integration for endemic non-communicable diseases
TABLE 5.10 General Principles of Warfarin Titration
INR Action
Greater than 5.0 or complaints of bleeding Hospitalize for warfarin adjustment
Above goal (INR elevated by more than 2.0) Stop warfarin for 2 daysDecrease warfarin dose by 1 mg
Above goal (INR elevated by less than 2.0) Evaluate for changes in medications or dietDecrease warfarin dose by 0.5–1 mg
At goal Continue current warfarin dose
Below goal Evaluate for changes in medications or dietAssess for nonadherenceIncrease warfarin dose by 0.5–1 mg
Below 1.5 If at high risk of embolic events, hospitalize for war-farin adjustment and possibly subcutaneous heparin or subcutaneous enoxaparin (Clexane) therapyAssess for nonadherence and discuss with the patient’s community health worker
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PROTOCOL 5.3'&"#.)94*'#84'*#4-*')9@&.@45')9'$5D"*#)9A'<$%6$%)9'5&*)9A')9'$..'-$#)49#*'&9'$9#)+&$A".$#)&9>'
NO
NO
YES
YES YES
NO
YES
YES
NO
NO
YES
NO
YES
YES YES
NO
NO
NO
YES
YES
NO
YES
Patient onwarfarin INR ≥ 5
INR ≥ 1above goal,
but ≤ 5
INR previouslyat goal
for ≥ 1 month1. Recheck INR in 2 weeks
INR at goalOR
≤ 1 abovegoal
INR lowerthan goal but
≥ 1.5
INR ≤ 1.5
Patienttaking
warfain?
Patienttaking
warfain?
Currentlyhospitalizedfor low INR
Currentlyhospitalized for
high INR
Reason forhigh INR identifiedand resolved (e.g.,overdose, acute
illness)
Currentlyhospitalizedfor high INR
1. Hold warfarin2. Admit to district hospital3. Consider reasons for high INR and address4. Recheck INR in 2 days
1. Continue warfarin2. Observe for 1 day, recheck INR3. If INR still near goal, discharge4. Recheck INR in one week
1. Restart warfarin at previous dose2. Observe for 1 day, recheck INR3. If INR still near goal, discharge4. Recheck INR in one week
1. Address reason for non-adherence2. Restart warfarin at previous dose3. Recheck INR in 1 week
1. Hospitalize2. Start enoxaprin OR, if enoxaparin
not available start heparin SC (Table 5.9)
1. Restart warfarin at lower dose (10%–20% lower than original dose)2. Observe for 1 day, recheck INR3. If INR still near goal, discharge4. Recheck INR in one week
1. Address reason for non-adherence2. Restart warfarin at previous dose3. Recheck INR in 3 days
1. Continue to hold warfarin2. Recheck INR in 2 days
1. Decrease warfarin by 10%–20%2. Recheck INR in 3 days
1. Increase warfarin by 10%–20%2. Recheck INR in 1 week
1. Increase warfarin by 10%–20%2. Recheck INR in 3 days
chapter!5 | cardiac surgery 131
PROTOCOL 5.3 Titrating Warfarin Therapy
5.10 Drug Supply and Patient Monitoring
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132 chronic care integration for endemic non-communicable diseases
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5.11 Dangers of Anticoagulation
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chapter!5 | cardiac surgery 133
Chapter 5!References
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134 chronic care integration for endemic non-communicable diseases
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chapter 6Chronic Kidney Disease
6.1 Etiology of Chronic Kidney Disease in Rural Rwanda
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TABLE 6.1 Causes of End-Stage Renal Disease in Sub-Saharan Africa and the U.S.
Glomerulonephritis or unknown
Hypertension Diabetes Other
Average (Nigeria and Senegal)1
54% 27.4% 11.9% 6.7%
USA3 15.4% 24.2% 37.3% 22.9%
136 chronic care integration for endemic non-communicable diseases
6.2 Screening for Renal Failure in High-Risk Populations
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6.2.3 HIV,?\')*'#8&"A8#'#&'+$"*4'%49$.'6$)."%4'-%):$%).7'#8%&"A8'5$:$A4'#&'#84'A.&:4%"."*C'%4*".#)9A')9',?\2%4.$#45'94-8%&-$#87'V,?\L`X>]Cg'Y#"5)4*')9'*"32Y$8$%$9'L6%)+$'%4-&%#',?\L`'-%4@$.49+4'#8$#'@$%)4*'37'-&-".$#)&9'$95'*4@4%)#7'&6',?\'5)*4$*4C'%$9A)9A'6%&:'Zm'#&'K0m'&6',?\'-$#)49#*>'
chapter!6 | chronic kidney disease 137
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TABLE 6.2 Relationship between Urine Dipstick and 24-hour Urine Protein Results
Urine dipstick result 24-hour urine protein
Top-normal Trace 150 mg
Microalbuminuria 1+ 200–500 mg
Proteinuria 2+ 0.5–1.5 gm
Nephrotic-range 3+ 2–5 gm
Nephrotic-range 4+ 7 gm
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138 chronic care integration for endemic non-communicable diseases
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6.3 Classification of Renal Failure
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TABLE 6.3'&"#.)94*'#84'5)664%49#'*#$A4*'&6'+8%&9)+'P)5947'5)*4$*4'VSM(X>'
SM(2UG?'4O"$#)&9>'SM('*#$A4*'/'$95'J'%464%'#&'-$#)49#*'<)#8'9&%:$.'A.&22
P)5947'):-$)%:49#'3"#'$%4'"*"$..7'$*7:-#&:$#)+>'G$#)49#*'<)#8'SM('K'$95'0'8$@4'*4@4%4'P)5947'57*6"9+#)&9>'H84*4'-$#)49#*'$%4'.)P4.7'#&'34A)9'4E-4%)49+)9A'*7:-#&:*>
YES
YES
YES
NO
NO
YES
NO
NO
YES
CKD 1 or 2(nl GFR, 2+
proteinuria, noinfection)
Referred to NCDclinic for suspectedor confirmed CKD
Check blood pressure, urine dipstick, HIV andelectrolyte panel including
creatinine, glucose, and hemoglobin
HIV
Consider early ARV initiation
ANY?1. Signs of urinary
obstruction (difficulty urinatingand abdominal pain or distention)?
2. Potassium ≥ 6.5 mEq/L?3. Di!culty breathing?
Refer to district hospitalfor admission
Obtain random urine proteinto creatinine ratio
≥ 3+ proteinuria ratio ≥ 3
1. Obtain serum albumin2. If CKD 1-3, start low-dose
ACE inhibitor unless contraindications (see Table 8.5)
3. Refer for evaluation for nephrotic syndrome by a nephrologist, internist, or pediatrician
1. If patients already followed in continuity clinic, (e.g., for HTN, DM or HIV) continue management in that clinic (at health- center level)
2. Start ACE inhibitor unless contraindication (see Table 8.5)3. Blood pressure goal ≤ 120/80 mmHg (see Table 8.5)4. Avoid NSAIDs, other nephrotoxins5. Return to NCD clinic once per year to check creatinine
chapter!6 | chronic kidney disease 139
TABLE 6.3 Stages of Chronic Kidney Disease
Degree of dysfunction Glomerular filtration rate
CKD 1 and 2 Proteinuria alone 60 ml/min/1.73m2
CKD 3 Moderate dysfunction 30–59 ml/min/1.73m2
CKD 4 and 5 Severe dysfunction 29 ml/min/1.73m2
6.4 Initial Evaluation and Management of Chronic Kidney Disease (CKD)
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PROTOCOL 6.1 Initial Evaluation of Chronic Kidney Disease Stage 1 or 2
140 chronic care integration for endemic non-communicable diseases
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2.&<45'$#'#84)%'"*"$.'84$.#8'+49#4%'+.)9)+'*)#4>'L9'LSU')98)3)#&%'*8&".5'34')9)#)$#45'$#'$'.&<'5&*4'V*44'TABLE 8.5X'<)#8'$'A&$.'3.&&5'-%4**"%4'
V`YL?(*XC'*"+8'$*')3"-%&649C'*8&".5'34'$@&)545'$.&9A'<)#8'T%'P)5947'#&E)9*>'L*'5)*+"**45'$3&@4C',?\2-&*)#)@4'-$#)49#*'*8&".5'34'+&9*)54%45'6&%'$9#)2%4#%&@)%$.'#84%$-7'%4A$%5.4**'&6'S(K'+&"9#'#&'-%4@49#'-%&A%4*2*)&9'&6'5)*4$*4>'G$#)49#*'<)#8'SM('/'&%'J'*8&".5'34'*449'&9+4'$'74$%')9'$'5)*#%)+#2.4@4.'`S('+.)9)+'#&'8$@4'#84)%'+%4$#)9)94'+84+P45'$95'#84)%'54A%44'&6'SM('%4$**4**45>
G$#)49#*'<)#8':&54%$#4'#&'*4@4%4'SM('VSM('BC'KC'&%'0X'*8&".5'34'+.&*4.7'4@$."$#45'6&%'%4@4%*)3.4'+$"*4*'&6'#84)%'5)*4$*4'V*44'PROTOCOL 6.2X>'G$#)49#*'<)#8'SM('K'&%'0'<)..'&6#49'34'*7:-#&:$#)+'$95')9)#)$.'4@$."$2#)&9'<)..'#$P4'-.$+4')9'#84'8&*-)#$.>'G$#)49#*'<)#8'SM('B'$%4'"*"$..7'
'$*'84$%#'6$)."%4X>
NO
YES
YES YES
YES
YES
NO
YES
NO
CKD 3(GFR 30–59)
Check blood pressure, urinedipstick, HIV and electrolyte
panel including creatinine andglucose and hemoglobin
Return in NCD clinic in 3-6 months to
recheck creatinine
HIV, DM, or heartfailure?
Control of underlying
disease process (e.g., glucose
control, ARVs)
CKD 4 or 5(GFR ≤ 29)
Assess and address symptoms
(see Protocol 6.3)
Fill out intake form for edematous conditions, including screening questions
for heart failure, TB, and a basic echocardiogram, and kidney ultrasound
CKD 3, 4, or 5(GFR ≤ 59)
Potentially reversible?Meets all criteria:1. No heart failure
2. No ultrasound signs of irreversiblekidney disease (see Table 6.3)
Refer to a nephrologist,internist, or pediatrician for
evaluation and possiblespecific therapy
Option for renal transplant?
Refer to a nephrologist, internist, or pediatrician
for evaluation and possible
specifictherapy
1. Start ACE unless contraindication
2. Start FeSO4 200 mg 3x/day x 30 days if Hb ≤ 10 g/dL
3. Goal BP ≤ 130/80 mmHg (see Table 8.5)
1. Control BP(goal ≤ 130/80)
2. Consider furosemide
3. Avoid ACEinhibitors(see Table 8.6)
Referred to NCDclinic for suspectedor confirmed CKD
ANY?1. Signs of urinary
obstruction (difficulty urinatingand abdominal pain or distention)?
2. Potassium ≥ 6.5 mEq/L?3. Di!culty breathing?
Refer to district hospitalfor admission
chapter!6 | chronic kidney disease 141
PROTOCOL 6.2 Initial Evaluation of Chronic Kidney Disease Stage 3, 4, and 5
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142 chronic care integration for endemic non-communicable diseases
$5".#':4$*"%4'dk/B'+:')9'.49A#8'$95'KkZ'+:')9'<)5#8>'L55)#)&9$..7C'#84'P)5947'+&%#4E'V&"#4%'-&%#)&9'&6'#84'&%A$9X')*'"*"$..7'%4.$#)@4.7'5$%PC'+&:-$%45'#&'*#%"+#"%4*'.)P4'#84'.)@4%'&9'".#%$*&"95'V*44'FIGURE 6.1'$95'FIGURE 6.2X>'R&*#'*&"%+4*'&6'%49$.'5)*4$*4'<)..'+$"*4'#84'P)5947*'#&'34+&:4'*:$..4%'$95'3%)A8#4%>'?:-&%#$9#'4E+4-#)&9*'$%4',?\'$95'5)$34#)+'94-8%&-$#87'V+&95)#)&9*'#8$#'$%4'9&#'#8&"A8#'#&'34'-$%#)+".$%.7'*#4%&)52%4*-&9*)@4X>
FIGURE 6.1 Normal Kidney Anatomy on Ultrasound (Arrowheads show the medullary pyramids, and star shows the outer cortex)
chapter!6 | chronic kidney disease 143
FIGURE 6.2 Ultrasound in Chronic Kidney Disease: Loss of Di"erentiation between Cortex and Medulla
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8$*'+&%%4.$#45'".#%$*&"95'$95'%49$.'3)&-*7'%4*".#*>/Z'H8)*'*#"57'6&"95'$5@$9+45C')%%4@4%*)3.4'5)*4$*4')9'gZm'&6'-$#)49#*'<8&'8$5'3'*:$..'
2)9A*'&9'".#%$*&"95'*8&".5'-%4+."54'#84'9445'6&%'*-4+)$.)*#'%464%%$.'V*44'TABLE 6.4X>
TABLE 6.4 Ultrasound Findings Specific for Severe, Irreversible Kidney Disease
1. Echogenic cortex (more than liver), plus a combined length 20 cm
2. Very small kidneys with a combined length less than 16 cm
b3*#%"+#)@4'94-8%&-$#87')*'$'-1#)$..7'%4@4%*)3.4'+$"*4'&6'%49$.'6$)."%4'#8$#'*8&".5'-%&:-#'8&*-)#$.'$5:)**)&9'6&%'6"%#84%'4@$."$#)&9'V*44''FIGURE 6.3X>
144 chronic care integration for endemic non-communicable diseases
FIGURE 6.3 Hydronephrosis on Ultrasound
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LSU2)98)3)#)&9'V*44'TABLE 8.5X>'S&9#%$)95)+$#)&9*')9+."54'$'-&#$**)":'A%4$#4%'#8$9'0':UOiF>'["%&*4:)54')*'&6#49'$'84.-6".'$5D"@$9#'#84%$-7>
H84':$9$A4:49#'&6'-$#)49#*'<)#8'SM('K'&%'0'<)#8&"#'$'%4@4%*)3.4'+$"*4'6&%'#84)%'5)*4$*4'54-495*'"-&9'#84'$@$).$3).)#7'&6'%49$.'#%$9*-.$9#$#)&9>'L..'-$#)49#*'*8&".5'8$@4'#84)%'3.&&5'-%4**"%4'+&9#%&..45')6'-&**)3.4>'LSU'
YES YES
NO
NO
YES
YES
NO
K 5–6 mEq/LStop these medicationsand return to NCD clinic
in two weeks
TakingACE inhibitors,
spironolactone or K supplement?
Estimated GFR ≤ 59
(CKD 3, 4, or 5)
Repeat K test
False positivedue to
hemolysisContinue usual follow-up
1. Start or increase furosemide dose (starting dose 20 mg orally 1 time per day) unless contraindication
2. Return to NCD clinic in two weeks
chapter!6 | chronic kidney disease 145
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6.5 Hyperkalemia
G&#$**)":'#4*#)9A'8$*'34+&:4')9+%4$*)9A.7'$@$).$3.4'$#'5)*#%)+#'8&*-)2#$.*')9';<$95$>'L..'-$#)49#*'4@$."$#45'6&%'SM('B'&%'8)A84%'$#'5)*#%)+#'`S('+.)9)+*'*8&".5'8$@4'#84)%'-&#$**)":'+84+P45')9)#)$..7>'?6'$'-$#)49#')*'%4+4)@)9A'-&#$**)":'*"--.4:49#$#)&9C'#84'-87*)+)$9'*8&".5':$P4'*"%4'#8$#')#')*'5)*+&9#)9"45'V*44'PROTOCOL 6.3X>'LSU')98)3)#&%*'$95'*-)%&9&2.$+#&94'*8&".5'34'5)*+&9#)9"45')::45)$#4.7>'?6'#84%4')*'$9'$39&%:$..7'
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PROTOCOL 6.3 Outpatient Management of Mild Hyperkalemia
146 chronic care integration for endemic non-communicable diseases
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6.6 Palliative Care for Chronic Kidney Disease
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chapter!6 | chronic kidney disease 147
&%'-%4*":45'+$"*4*C'$95'%4+&::49545'#%4$#:49#*'$%4'.)*#45')9'TABLE 6.5'$95'TABLE 6.6>
TABLE 6.5 Common Physical Symptoms in Advanced Chronic Kidney Disease and Their Treatment18
Physical symptom Cause Treatment (see Chapter 2 for details)
Fatigue and drowsiness86%
Depression Assess for depression and treat if found.
Fluid overload Diurese for fluid overload, if needed.
Anemia, poor nutrition, other organ failure, uremia, insomnia
Itch84%
Dry skin Emollients for dry skin.
Secondary hyperparathyroidismHyperphosphatemiaAnemiaOpioids
Antihistamine such as diphenhydramine (can worsen fatigue and delirium).Steroid.
Dyspnea (the most distressing symptom)80%
Pulmonary edemaPleural e#usionMetabolic acidosisAnemiaAspirationComorbid CHF, COPD, or other lung pathology
If comfort and quality of life are the only goals of care, not preservation of renal function, diurese for symptomatic pulmonary or peripheral edema.Opioid relieves dyspnea of any cause. Renal dosing for morphine (see APPENDIX A).
Delirium (agitated or hypoactive)76%
Metabolic derangementsHypoxia/hypercapniaMedications
Reduce or eliminate culprit medications, if possible.Haloperidol.
Pain73%
Bone pain due to 2̊ hyperparathyroidismDiabetic neuropathyPolycystic kidney diseaseCalciphylaxis (hemodialysis patients only)
Avoid NSAIDS due to nephrotoxicity and increased risk of bleeding with uremic platelet dysfunction.Paracetamol is safe and requires no dose adjustment for renal failure.Morphine: active metabolite accumulates in CKD 5 and can cause neurotoxicity. Use lower dose and/or longer dosing interval than usual.
Anorexia71%
Nausea (see below)Diabetic gastroparesisDry mouth
Anti-emetics (see below).Metoclopramide for gastroparesis.Oral care.Steroid to stimulate appetite.
Swelling in legs/arms71%
Fluid overloadLow oncotic pressure due to proteinuria and malnutritionComorbid heart failure
Elevate edematous extremities. Elastic wraps as tolerated.If comfort and quality of life are the only goals of care, not preservation of renal function, diurese for symptomatic peripheral edema or anasarca.
Dry mouth69%
Intravascular volume depletion (can exist even with total body fluid overload).
Instruct family caregivers to keep mouth moist with sips of liquid or sponge.
148 chronic care integration for endemic non-communicable diseases
Physical symptom Cause Treatment (see Chapter 2 for details)
Constipation65%
Medications including opioids and anticholinergicsIntravascular volume depletion
Laxative
Nausea with or without vomiting59%
UremiaEmetogenic medicationsDiabetic gastroparesis
Reduce or eliminate culprit medications, if possible.Haloperidol for nausea due to endogenous or exog-enous emetogenic toxin. Start with low dose.Metoclopramide for gastroparesis.
Cough47%
Pulmonary edemaAspirationComorbid COPD or other lung pathology
If comfort and quality of life are the only goals of care, not preservation of renal function, diurese for symptomatic pulmonary edema.Opioid relieves cough of any cause. Renal dosing for morphine.
TABLE 6.6 Common Psychological Symptoms in Advanced Chronic Kidney Disease and Their Treatment
Psychological symptom Treatment
Anxiety78%
Psychosocial supportsHaloperidolDiazepam (can cause delirium and paradoxical agitation)
Feeling sad65%
Psychosocial supports
DepressionUnknown prevalence
Psychosocial supportsAntidepressant such as fluoxetine or amitriptyline
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6.7 Renal Replacement Therapy (Hemodialysis and Peritoneal Dialysis)
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chapter!6 | chronic kidney disease 149
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6.8 Renal Transplantation
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150 chronic care integration for endemic non-communicable diseases
6.9 Acute Kidney Failure in Hospitalized Patients
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chapter!6 | chronic kidney disease 151
Chapter 6!References
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152 chronic care integration for endemic non-communicable diseases
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chapter 7Diabetes
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154 chronic care integration for endemic non-communicable diseases
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chapter!7 | diabetes 155
7.1 Opportunistic Identification and Screening for Diabetes in Acute Care Health Center Clinics
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156 chronic care integration for endemic non-communicable diseases
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TABLE 7.1 Diabetes Diagnosis: Blood Sugar Measurement and Symptoms
Blood sugar 126 mg/dL (7 mmol/L) fastingOR
200 mg/dL (11 mmol/L) random with symptomsOR
200 mg/dL (11 mmol/L) with an oral glucose tolerance test
Glycosylated hemoglobin (HbA1c) 6.5% (using a point-of-care device)
Symptoms of chronic hyperglycemia Polyuria (excessive urination)Polydipsia (excessive thirst)Weight loss
Imm
edia
tely
tran
sfer
toho
spita
l
Cons
ider
oth
erca
uses
of t
hepa
tient
’s sy
mpt
oms
and
tran
sfer
toho
spita
l
Chec
k a
finge
r stic
k bl
ood
gluc
ose
Chec
k a
urin
edi
pstic
k
Any
glyc
osur
ia o
run
able
toch
eck
Hyp
ergl
ycem
ia u
nlik
ely
tobe
cau
se o
f sym
ptom
s.Co
nsid
er o
ther
etio
logi
es
Bloo
d su
gar
≥ 15
0 m
g/dL
(8.3
mm
ol/L
)
Age
≤ 18
Li
kely
type
1 di
abet
es m
ellit
us,
refe
r to
dist
rict h
ospi
tal f
or in
patie
nt c
onfir
mat
ion
ofdi
agno
sis a
nd li
kely
initi
atio
n of
insu
lin th
erap
y
Pres
ent t
o ac
ute
care
cl
inic
with
any
of t
he
follo
win
g sy
mpt
oms:
1. D
ehyd
ratio
n2.
Fre
quen
t urin
atio
n3.
Thi
rst
4. In
crea
sed
appe
tite
5. W
eigh
t los
s or g
ain
Bloo
d su
gar
200-
400
mg/
dL(1
1–22
mm
ol/L
)?
Any
war
ning
sign
s:1.
Slo
w, d
eep
brea
thin
g 2.
“Fru
ity” b
reat
h3.
Abd
omin
al p
ain,
nau
sea,
vom
iting
4. S
leep
y, n
ot re
spon
ding
5. B
lood
pre
ssur
e ≤
90/
60 m
mH
g
Like
ly ty
pe 2
or m
ixed
dia
bete
s mel
litus
, ref
er
to d
istric
t NCD
clin
ic fo
r con
firm
atio
n of
di
agno
sis a
nd in
itiat
ion
of o
ral h
ypog
lyce
mic
s (P
roto
col 7
.2)
Bloo
d su
gar
≥ 40
0 m
g/dL
(22
mm
ol/L
)?
YES
NO
YES
NO
YES
YES
NO
NO
NO
YES
NO
YES
1. A
dults
: giv
e 50
0 m
l nor
mal
salin
e (N
S)
bolu
s, th
en c
ontin
ue N
S at
250
cc/
hour
. Ch
ildre
n ≤
12 y
ears
old
: giv
e 20
ml/
kg N
S bo
lus,
then
con
tinue
at m
aint
enan
ce d
ose
2. G
ive
0.2
U/k
g (o
r 10
units
for a
n ad
ult)
SC
of re
gula
r ins
ulin
3. C
heck
blo
od su
gar e
very
hou
r and
giv
e ad
ditio
nal i
nsul
in u
ntil
tran
sfer
(Tab
le 7
.3)
chapter!7 | diabetes 157
PROTOCOL 7.1 Diagnosis of Diabetes and Management of Hyperglycemia at Health-Center Level
158 chronic care integration for endemic non-communicable diseases
7.2 Recognition and Treatment of Emergency States (Hyperglycemia and Hypoglycemia)
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TABLE 7.2 Danger Signs in Hyperglycemia
Early findings Notes
Signs of dehydration Dry mucus membranes, skin tenting, decreased urine output
Hypotension From loss of fluids
Slow, deep breathing From ketosis
Abdominal pain, nausea and vomiting
Fruity breath Ketones have a fruity odor
Late findings (neurological) Notes
Focal motor deficits
Altered mental status Agitation, sleepiness, eventually coma
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chapter!7 | diabetes 159
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*#)+P'3.&&5'A."+&*4>
TABLE 7.3 Insulin Therapy of Patients with Hyperglycemia ( 250 mg/dL) and Danger Signs Awaiting Transfer
Blood sugar Regular insulin dose (given subcutaneously)
For children ( 40 kg) For adults
Initial bolus 0.2 units/kg x 1 10 units
Recheck blood glucose every hour
250 mg/dL (13 mmol/L) 0. 1 unit/kg/hour 5 units/hour
150–250 mg/dL (8–13 mmol/L) 0.05 unit/kg/hour 2.5 units/hour
150 mg/dL ( !8 mmol/L) Stop insulin, continue normal saline or lactated ringers
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160 chronic care integration for endemic non-communicable diseases
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chapter!7 | diabetes 161
TABLE 7.4 Diagnosis and Treatment of Hypoglycemia
Symptoms Somnolence or agitationConfusionLethargyDizziness, nauseaSeizuresStroke-like symptomsSweatingTremorsPalpitations, anxiety
Causes Correctable:Overdose of medication (insulin or orals)Increased exerciseSkipped meals
Not (easily) correctable:Reduced renal function (diminished clearance of hypoglycemic agents)Liver failure (inability to produce glycogen to correct serum hypoglycemia)
Treatment Juice, soft drink, sugar water (if able to follow commands)In adults IV glucose 50% solution (if unable to follow commands)In children 12 give glucose 50% solution by nasogastric tube (if unable to follow commands)3–12 hours of frequent finger-stick checks
7.3 Principles and Initial Management of Diabetes
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162 chronic care integration for endemic non-communicable diseases
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TABLE 7.5 Glucose Control Goals
Reasonable control More intensive control
Pre-meal and pre-bedtime glucose
150–180 mg/dL(8.3–10 mmol/L)
120–150 mg/dL (6.7–8.3 mmol/L)
Hemoglobin A1c 7.5%–8%: average blood glucose of170–185 mg/dL (9.4–10.5 mmol/L)
7.0%–7.5%: average blood glucose of154–170 mg/dL (8.6–9.4 mmol/L)
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Refe
r to
dist
rict c
linic
for i
nsul
in th
erap
ySt
op g
liben
clam
ide
Firs
t visi
t or
not o
nth
erap
y?
Cont
inue
cur
rent
di
abet
es
med
icat
ions
Star
t m
etfo
rmin
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0 m
g da
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urag
e w
eigh
t los
s
Follo
w-u
p 2–
4 w
eeks
Follo
w-u
p 4–
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NO
YES
NO
YES
YES
YES
NO
NO
YES
NO
NO
YES
YES
NO
Patie
nt in
dist
rict N
CD c
linic
w
ith c
onfir
med
dia
bete
s, no
t on
insu
lin
1. A
ny w
arni
ng si
gns (
see
Tabl
e 7.
2 )
A
ND
glu
cose
≥ 2
00 m
g/dL
(11 m
mol
/L)
O
R2.
Glu
cose
≥ 4
00 m
g/dL
(22.
2 m
mol
/L)
Hyp
ogly
cem
ia(s
ee T
able
7.4
)≥
2x
since
last
visi
t
Dec
reas
e do
se(s
ee T
able
7.6
). En
cour
age
regu
lar m
eals
Incr
ease
dos
e(s
ee T
able
7.6
)
BMI ≥
25
kg/m
2 Co
rrec
tabl
eca
use
of h
ypog
lyce
mia
?
Glu
cose
cont
rol a
t goa
l?(s
ee T
able
7.5
)
Star
t glib
encl
amid
e,
5 m
g in
the
mor
ning
1. S
tart
NS
at 2
50 c
c/ho
ur2.
Giv
e 0.
2 U
/kg
(or 1
0 un
its fo
r an
adul
t) S
C of
regu
lar i
nsul
in if
gluc
ose ≥
250
mg/
dL (1
3.8
mm
ol/L
) 3.
Che
ck b
lood
suga
r eve
ry h
our a
nd g
ive
addi
tiona
l ins
ulin
unt
il
tr
ansf
er (s
ee T
able
7.3
)
Max
imum
dos
e of
gl
iben
cam
ide
and
met
form
in
Cont
inue
cur
rent
di
abet
es m
edic
atio
ns.
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re a
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regu
lar
mea
ls/sn
acks
. N
utrit
iona
l sup
port
if
need
ed
chapter!7 | diabetes 163
PROTOCOL 7.2 Treatment of Diabetes with Oral Hypoglycemic Agents (in Adults)
164 chronic care integration for endemic non-communicable diseases
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TABLE 7.6 Oral Hypoglycemic Therapy
Steps Metformin Glibenclamide
7 a.m. 7 p.m. 7 a.m. 7 p.m.
1 500 mg - 5 mg -
2 500 mg 500 mg 5 mg 5 mg
3 1000 mg 500 mg 10 mg 5 mg
4 1000 mg 1000 mg 10 mg 10 mg
5 Add glibenclamide Add metformin
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chapter!7 | diabetes 165
TABLE 7.7 Common Causes for Hyperglycemia in Patients on Insulin
Problems with insulin injection and mixing technique
Problems with insulin storage or expiration
Unusual dietary excess
Active infection (e.g., malaria, urinary, skin, or pulmonary)
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7.4 Management of Diabetes with Insulin Therapy
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166 chronic care integration for endemic non-communicable diseases
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TABLE 7.8 Indications for Insulin Therapy
Type 1 diabetes
Failed maximum oral therapy
Pregnancy
Creatinine greater than 150 mmol/L (1.6 mg/dL) (which prevents use of metformin),and unable to control glucose with glibenclamide alone
History of diabetic ketoacidosis
Child 18 years of age
Firs
t visi
t fo
r ins
ulin
Refe
r to
hosp
ital
for
adm
issio
n
Cont
inue
cur
rent
di
abet
es m
edic
atio
ns.
Follo
w-u
p 4–
8 w
eeks
Glu
cose
cont
rol a
t goa
l?
(see
Tab
le 7
.5)
Iden
tify
insu
lin
regi
men
(sta
rted
as i
npat
ient
)
Follo
w-u
p 2–
4 w
eeks
Ensu
re a
cces
s to
regu
lar m
eals
/sna
cks.
Nut
ition
al su
ppor
t as n
eede
d.
Hyp
ogly
cem
ia?
NO
YES
YES
NO
NO
YES
YES
YES
NO
NO
Trea
t inf
ectio
n, O
R ch
ange
insu
lin b
atch
, O
R en
sure
goo
d in
sulin
stor
age
and
inje
ctio
n te
chni
ques
.
NO
YES
Dia
bete
s mel
litus
AN
DA
lread
y on
insu
linO
RH
as n
ew in
dica
tion
for i
nsul
in th
erap
y(s
ee T
able
7.8
)
1. A
ny W
arni
ng S
igns
(see
Tab
le 7
.2)
AN
D
gluc
ose ≥
200
mg/
dl (1
1 mm
ol/L
)O
R2.
Glu
cose
≥ 4
00 m
g/dl
(22.
2 m
mol
/L)
1. A
dults
: giv
e 50
0 m
l nor
mal
salin
e (N
S) b
olus
, the
n co
ntin
ue N
S at
250
cc/
hour
. Chi
ldre
n ≤
12 y
ears
old
: giv
e 20
ml/
kg N
S bo
lus,
then
con
tinue
at m
aint
enan
ce d
ose
2. G
ive
0.2
U/k
g (o
r 10
units
for a
n ad
ult)
SC
of
regu
lar i
nsul
in if
glu
cose
≥ 2
50 m
g/dL
(13
mm
ol/L
)3.
Che
ck b
lood
suga
r eve
ry 1–
4 ho
urs a
nd g
ive
ad
ditio
nal i
nsul
in u
ntil
tran
sfer
(see
Tab
le 7
.3)
Corr
ecta
ble
caus
e of
hype
rgly
cem
ia?
(see
Tab
le 7
.7)
Incr
ease
insu
lin(s
ee T
able
7.10
)
Dec
reas
e in
sulin
(see
Tab
le 7
.10)
Corr
ecta
ble
caus
e of
hypo
glyc
emia
?(s
ee T
able
7.4
)
If on
ora
l med
icat
ions
:1.
Sto
p gl
iben
clam
ide
2. C
ontin
ue m
etfo
rmin
chapter!7 | diabetes 167
PROTOCOL 7.3 Initiation and Adjustment of Insulin Regimens
168 chronic care integration for endemic non-communicable diseases
7.4.1 Initiation of Insulin Therapyb9+4'#84'54+)*)&9'#&'*#$%#')9*".)9'8$*'3449':$54C'-$#)49#*'*8&".5'34'%464%%45'#&'#84'5)*#%)+#'8&*-)#$.'6&%'$5:)**)&9>'?9'#84'8&*-)#$.C'#84'6&..&<2)9A'*#4-*'<)..'34'#$P49W
O!"&-02*&2,#"=2;0%*'"8*,&2#0-*;0&2*C2"=#0"%M2,&2;"V*;<;2%,10+
Q8,)2-=*K0&'=";*%0+'Y)9+4'A.)349+.$:)54'*#):".$#4*')9*".)9'*4+%4#)&9'37'#84'-$9+%4$*C')#*'+&9#)9"45'"*4')9'#84'*4##)9A'&6')9*".)9'#84%$-7'+$9')9+%4$*4'#84'%)*P'&6'87-&A.7+4:)$>'[&%'#8)*'%4$*&9C'A.)349+.$:)54'*8&".5'34'5)*+&9#)9"45')9'$..'-$#)49#*'&9')9*".)9>
'R4#6&%:)9'*8&".5'34'+&9#)9"45')9'-$#)49#*'<8&'$%4'34A)929)9A')9*".)9'#84%$-7>'R4#6&%:)9'+$"*4*'#84'3&57=*'#)**"4*'#&'34##4%'%4*-&95'#&')9*".)9C'%4*".#)9A')9'54+%4$*45'84-$#)+'A."+&*4'&"#-"#>'R4#6&%:)9':$7'.&<4%')9*".)9'5&*4'%4O")%4:49#*>
Q8"#82*&1<=*&+'?9'#84'8&*-)#$.C'-$#)49#*'<)..'34'*#$%#45'&9'$9')9*".)9'%4A):49'#8$#')*'$--%&-%)$#4'6&%'#84:'V*44'SECTION 7.4.2X>
L#,$*%02)"8*0&820%<'"8*,&+'_8).4'8&*-)#$.)^45C'-$#)49#*'*8&".5'34'A)@49'45"+$#)&9'%4A$%5)9A'#84'$--%&-%)$#4')9D4+#)&9'&6')9*".)9'$95'#84'):-&%#$9+4'&6'%4A".$%':4$.*>
W&1<#02-,,%2,<8)"8*0&82C,==,4B<)2)="&+'L#'5)*+8$%A4C'$'+&::"9)#7'84$.#8'<&%P4%'*8&".5'34'$**)A945'#&'#84'-$#)49#>'H8)*'+&::"9)#7'
<44P*C'+84+P'$95'%4+&%5'5$).7'3.&&5'A."+&*4'.4@4.*>'H84'-$#)49#'*8&".5'$.*&'34'A)@49'$9'$--&)9#:49#'6&%'&94'<44P'$6#4%'5)*+8$%A4'#&'34'4E$:)945'$#'#84'5)*#%)+#2.4@4.'`S('+.)9)+>'H84'):-&%#$9+4'&6'6&..&<2"-'*8&".5'34'4:-8$*)^45'#&'#84'-$#)49#>
7.4.2 Insulin Regimen Selection?9*".)9'*8&".5'34':$54'$@$).$3.4'$#'#84'84$.#82+49#4%'[email protected]'$.&9A'<)#8'$--%&-%)$#4'#%$)9)9A')9')#*'"*4>'[&%'$'-%&A%$:'#8$#')*'%4.$#)@4.7'94<')9'$'5)*#%)+#C')#':$7'34'-%464%$3.4'#&':$9$A4')9*".)9254-49549#'-$#)49#*'<)#8'5)$34#4*'$#'#84'5)*#%)+#'[email protected]'<84%4'9"%*4'+.)9)+)$9*'8$@4':&%4'4E#49*)@4'#%$)9)9A'$95'-87*)+)$9*'$%4'$@$).$3.4'#&'*"-4%@)*4>',&<4@4%C')9':&*#'+$*4*C'-$#)49#*'.)@4'6"%#84%'6%&:'#84'5)*#%)+#'+.)9)+*'#8$9'6%&:'84$.#82+49#4%'+.)9)+*>'?9'*"+8'*)#"$#)&9*C'$'+&::"9)#7'84$.#8'<&%P4%')*'@)#$.'#&'49*"%)9A'#8$#'-$#)49#*'5&'9&#'%"9'&"#'&6')9*".)9>'H84'+&::"9)#7'84$.#8'<&%P4%'&%'
-&**)3.4'#&'54+49#%$.)^4')9*".)9':$9$A4:49#'#&'#84'84$.#82+49#4%'+.)9)+C'&9+4'$'-$#)49#'8$*'4*#$3.)*845'$'*#$3.4'%4A):49>
?9';<$95$C'#84%4'$%4'#8%44'#7-4*'&6')9*".)9'$@$).$3.4'#8%&"A8'-"3.)+'-8$%:$+)4*'V*44'TABLE 7.9XW'`G,'V24*./(,(#)'&%'/'4,'XC'%4A".$%'V24*./24'+
chapter!7 | diabetes 169
#(12)'XC'$95'+&:3)9$#)&9'V-26,''&%'-26,(#)X>'`G,')*'A494%$..7'+&9*)54%45'#&'34'$'3$*$.')9*".)9h')#'-%&@)54*'$'.&9A2$+#)9A'3$*4.)94')9*".)9'.4@4.>'b9'#84'T%'8$95C'%4A".$%')9*".)9')*'*8&%#4%2$+#)9AC'$95')*'#8"*'"*"$..7'"*45'#&'#%4$#':4$.#):4'A."+&*4'*"%A4*>'S&:3)9$#)&9')9*".)9')*'$'#8)%5'&-#)&9C'<8)+8'+&9*)*#*'&6'$'-%4:$54':)E#"%4'&6'%4A".$%'$95'`G,')9*".)9>'H84':&*#'+&::&9'%$#)&'6&%'-%42:)E45')9*".)9')*']1iB1'V]1m'`G,C'B1m'%4A".$%X>
TABLE 7.9 Properties of Insulin Available in Rwanda
Regular (rapide) NPH (insulatard or lente) Combination (70/30 or mixte)
Time to onset 20–30 minutes 1–2 hours 30 minutes
Peak e#ect 2.5–5 hours 4–12 hours 3–8 hours
Duration 4–12 hours 18–24 hours 18–24 hours
Dosing 20–30 minutes before meals
Once or twice daily, around 7 am and 7 pm (or bedtime)
20–30 minutes before breakfast and/or dinner
Vial appearance (manufacturer-specific)
Clear Cloudy Cloudy
H84'$@$).$3.4'#7-4*'&6')9*".)9'+$9'34'"*45')9')*&.$#)&9'&%')9'@$%)&"*'+&:23)9$#)&9*'#&'$+8)4@4'#84'54*)%45'4664+#>'Y):-.4%'%4A):49*'%4*".#')9'.&&*4%'A."+&*4'+&9#%&.'#8$9'#84'+&:-.4E'%4A):49*>'b6'+&"%*4C':&%4'+&:-.4E'
-$#)49#*'"*)9A')9*".)9'*8&".5'8$@4'$++4**'#&'%4A".$%'$**)*#$9+4'6%&:'$'#%$)945'+&::"9)#7'84$.#8'<&%P4%>'
H84')9)#)$.'%4A):49'<)..'34'54#4%:)945')9'#84')9-$#)49#'*4##)9AC'3"#')#':$7'9445'#&'34'$5D"*#45'$6#4%'#84'-$#)49#')*'5)*+8$%A45>'H84'*):-.4*#')9*".)9'%4A):49')*'$'*)9A.4'9)A8##):4')9D4+#)&9'&6'`G,>'H8)*'$--%&$+8'#$%A4#*'#84'6$*#)9A'3.&&5'*"A$%'$95'+$9'*4%@4'$*'$'3").5)9A'3.&+P'6&%'6"#"%4'$5D"*#:49#*C')6'944545>
H8)*'*#%$#4A7'8$*'3449'*8&<9'#&'+&9#%&.'A."+&*4')9'%&"A8.7'8$.6'&6'-$#)49#*'<)#8'5)$34#4*')9'$'a>Y>'-&-".$#)&9>Kg',&<4@4%C')9'&"%'4E-4%)49+4C':&*#'-$#)49#*')9'%"%$.';<$95$'+$99&#'34'+&9#%&..45'&9'$'&9+42$25$7'%4A):49>'H8)*':$7'34'34+$"*4'#84)%')9*".)9'*4+%4#)&9')*':&%4'):-$)%45'#8$9')9'#84'$@4%$A4'-$#)49#'<)#8'#7-4'J'5)$34#4*')9'$9')95"*#%)$.)^45'*4##)9A>'R&*#'&6'&"%'-$#)49#*'%4O")%4'#<)+425$).7'`G,'<)#8'%4A".$%')9*".)9'&%'#<)+4'5$).7'-%42:)E45')9*".)9>'H84*4'%4A):49*'$@&)5'*4@4%4'87-4%A.7+4:)$'5"4'#&'+$%3&875%$#42%)+8':4$.*>'TABLE 7.10'&"#.)94*'#84'$@$).$3.4')9*".)9'%4A):49*')9'&%54%C'6%&:'*):-.4*#'#&':&*#'+&:-.4E>'H84':&*#'+&::&9.7'"*45'%4A):49*')9';<$95$'$%4'8)A8.)A8#45')9'%45>
170 chronic care integration for endemic non-communicable diseases
TABLE 7.10 Insulin RegimensRe
gim
enIn
ject
ions
Cove
rage
of
bas
al
glyc
emia
Cove
rage
at
mea
lsN
otes
Star
ting
dose
type
1St
artin
g do
se ty
pe 2
NPH
(ins
ulat
ard
or le
nte)
1x/d
ay1
Som
eN
one
Mos
t sim
ple,
but
not
goo
d co
vera
ge
if hi
gh-c
arbo
hydr
ate
diet
Not
app
ropr
iate
0.2
units
/kg/
day
or
10 u
nits
/day
(whi
chev
er is
le
ss) g
iven
at b
edtim
e
NPH
(ins
ulat
ard
or le
nte)
2x/
day
2G
ood
Non
eG
ood
for s
ome
patie
nts w
ith ty
pe
2 di
abet
es, b
ut a
gain
pro
blem
with
co
vera
ge if
hig
h-ca
rboh
ydra
te d
iet
Not
app
ropr
iate
0.3–
0.6
units
/kg/
day:
60%
pre
-bre
akfa
st,
40%
pre
-din
ner
(20–
30 m
inut
es b
efor
e m
eal)
70/3
0 (m
ixte)
2x
/day
2
Goo
dBr
eakf
ast a
nd
dinn
er (n
o lu
nch
cove
rage
)
Post
-pra
ndia
l hyp
ergl
ycem
ia. F
or
high
-car
bohy
drat
e di
ets,
may
nee
d cl
oser
to a
50/
50 m
ix
Not
app
ropr
iate
0.3–
0.6
units
/kg/
day:
50
% p
re-b
reak
fast
, 50
% p
re-d
inne
r(2
0–30
min
utes
bef
ore
mea
l)
NPH
(ins
ulat
ard
or le
nte)
and
re
gula
r (ra
pide
) In
sulin
2x/
day
2G
ood
Brea
kfas
t and
di
nner
Lunc
h m
ay
be c
over
ed b
y m
orni
ng N
PH
Allo
ws p
atie
nts t
o co
ntro
l mix
Patie
nts c
ombi
ne in
sulin
from
two
vial
s (N
PH a
nd re
gula
r) a
nd g
ive
th
e in
ject
ion
2x/d
ay
0.2–
0.3
units
/kg
0.5–
0.7
units
/kg
Giv
e 50
% o
f dos
e as
NPH
60%
pre
-bre
akfa
st40
% p
re-d
inne
rG
ive
50%
of d
ose
as re
gula
r(s
plit
even
ly p
re-b
reak
fast
and
pre
-din
ner,
20
–30
min
utes
bef
ore
mea
l)
Basa
l/Pr
andi
al3
Goo
dA
ll m
eals
Best
for l
arge
mid
day
mea
ls D
inne
r-tim
e N
PH a
nd re
gula
r co
mbi
natio
n. R
egul
ar a
lone
with
br
eakf
ast a
nd lu
nch
0.2–
0.3
units
/kg
0.5–
0.7
units
/kg
Giv
e 50
% o
f dos
e as
NPH
One
dos
e pr
e-di
nner
com
bine
d w
ith d
inne
r-tim
e re
gula
r in
sulin
Giv
e 50
% o
f dos
e as
regu
lar
(spl
it ev
enly
and
giv
en 2
0-30
min
utes
prio
r to
mea
ls)
chapter!7 | diabetes 171
7.5 Insulin Use in the Community
R&1<=*&2*&X0'8*,&+2H7-)+$..7C')9*".)9')9D4+#)&9*'*8&".5'34'A)@49')9'#84'*"3+"#$94&"*'6$#'&6'#84'$35&:49>'L.#4%9$#)@4'*)#4*')9+."54'#84'*"3+"#$294&"*'6$#'&6'#84'#8)A8*'$95'$%:*>'H84'$35&:)9$.'6$#')*'A494%$..7'#8&"A8#'#&'34'#84'34*#'*)#4'6&%'$3*&%-#)&9'34+$"*4')#'+&9#$)9*'$'A%4$#4%'6$#2#&2:"*+.4'%$#)&>',&<4@4%C'<)#8'%4-4$#45')9D4+#)&9*C':$97'-$#)49#*'54@4.&-'-$)9C'+$.."*4*C'&%'3%")*)9AC'$95'*&:4#):4*'#847'-%464%'$.#4%9$#)9A'*)#4*>'[&%'#8)*'%4$*&9C')#':$7'34'%4$*&9$3.4'#&'%4+&::495'#8$#':&%9)9A')9D4+2#)&9*'34'A)@49'$#'$35&:)9$.'*)#4*C'$95'4@49)9A')9D4+#)&9*')9'#84'#8)A8>'H84'4:-8$*)*'*8&".5'6&+"*'&9'#84'+&9*)*#49#'"*4'&6'#84'*)#4'&%'*)#4*C')9'&%54%'#&'49*"%4'%4.)$3.4'$3*&%-#)&9>
R&1<=*&218,#"-0+'?6')9*".)9')*'*#&%45'):-%&-4%.7C')#':$7'9&#'8$@4'#84'54*)%45'4664+#>'[&%'-$#)49#*'<8&'8$@4'87-4%A.7+4:)$'54*-)#4'4*+$.$#)9A'5&*4*'&6')9*".)9C'-%&-4%')9*".)9'*#&%$A4'*8&".5'34'%4@)4<45'<)#8'#84'-$#)49#>'?9'$9')54$.'*4##)9AC')9*".)9'*8&".5'34'%46%)A4%$#45>',&<4@4%C'#8)*')*'):-%$+#)+$.'$95'-%&3$3.7'"994+4**$%7')9'%"%$.';<$95$'$95')9':&*#'T%'.):)#452%4*&"%+4'*4##)9A*>'L.#4%9$#)@4.7C'-$#)49#*'+$9'-.$+4'#84'@)$.')9'$'*:$..'+&9#$)94%'&6'<$#4%C'<8)+8'*8&".5'34'P4-#')9'$'+&&.'-.$+4'&"#'
"*45>'[&%#"9$#4.7C';<$95$'8$*'$'#4:-4%$#4'+.):$#4>'?9'T%C'8&##4%'+&"9#%)4*C'%46%)A4%$#)&9':$7'34'$@$).$3.4'#8%&"A8'.&+$.'*&6#'5%)9P'5)*2#%)3"#&%*>'H84%4')*'.)##.4'4@)549+4'#8$#'-%&3.4:*'<)#8')9*".)9'*#&%$A4'$%4'+"%%49#.7'$':$D&%'3$%%)4%'#&'A&&5'&"#+&:4*'6&%'-$#)49#*'<)#8'5)$34#4*')9'*"+8'$%4$*>Kd
172 chronic care integration for endemic non-communicable diseases
TABLE 7.11 Example of Glucose Monitoring Chart
Dat
eBe
fore
bre
akfa
stSy
mpt
oms
of
hype
rgly
cem
ia/
hypo
glyc
emia
Befo
re lu
nch
Sym
ptom
s of
hy
perg
lyce
mia
/ hy
pogl
ycem
ia
Befo
re d
inne
rSy
mpt
oms
of
hype
rgly
cem
ia/
hypo
glyc
emia
Befo
re b
edtim
e
Bloo
d su
gar
Insu
linBl
ood
suga
rIn
sulin
Bloo
d su
gar
Insu
linBl
ood
suga
rIn
sulin
Day
1
183
mg/
dL2U
Reg
ular
Non
e2U
Reg
ular
Non
e12
5 m
g/dL
7U N
PH
2U R
egul
arN
one
Day
2
2U R
egul
arN
one
240
mg/
dL2U
Reg
ular
Non
e7U
NPH
2U
Reg
ular
Non
e72
mg/
dL
Day
3
170
mg/
dL2U
Reg
ular
Non
e2U
Reg
ular
Non
e15
0 m
g/dL
7U N
PH
2U R
egul
arN
one
Day
4
2U R
egul
arN
one
204
mg/
dL2U
Reg
ular
Non
e7U
NPH
2U
Reg
ular
Non
e57
mg/
dL
chapter!7 | diabetes 173
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174 chronic care integration for endemic non-communicable diseases
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chapter!7 | diabetes 175
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TABLE 7.12 Principles for Adjusting Insulin 70/30 (Mixte) or 2x/day NPH Regimens
Timing of hyperglycemia/ hypoglycemia
Hyperglycemia(documented)
Hypoglycemia(documented OR symptoms)
Morning/overnight Increase dinner-time or evening insulin by 2 units
Decrease dinner-time or evening basal insulin by 4 units or 10%, whichever is greater
Mid-day/evening Increase morning insulin by 2 units Decrease morning insulin by 4 units or 10%, whichever is greater
TABLE 7.13 Principles for Adjusting Combined Basal (NPH) and Prandial (Regular Insulin) Regimens
Hyperglycemia(documented)
Hypoglycemia(documented OR symptoms)
Middle of the night n/a Decrease PM Regular 2–4 U
Before breakfast Increase PM NPH 2 U Decrease PM NPH 2–4 U
Mid-day Increase AM Regular 2 U Decrease AM Regular 2–4 U
Before dinner Increase AM NPH 2 U Decrease AM NPH 2–4 U
Before bedtime Increase Pre-dinner Regular 2 U
Decrease Pre-Dinner Regular 2–4 U
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176 chronic care integration for endemic non-communicable diseases
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chapter!7 | diabetes 177
TABLE 7.14 Example of Transitioning from 70/30 (Insuline Mixtard) to NPH/Regular (Insuline Lente + Rapide)
Initial dose: Pre-breakfast Pre-dinner
70/30 (Insuline mixtard) 20 units 10 units
Final dose: Pre-breakfast Pre-dinner
NPH (Insuline lente) 14 units (70% of 20 units) 7 units (70% of 10 units)
Regular (Insulin rapide) 6 units (30% of 20 units) 3 units (30% of 10 units)
7.6 Adjuvant Therapies and Routine Monitoring for Complications in Patients with Diabetes
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178 chronic care integration for endemic non-communicable diseases
TABLE 7.15 Common Complications of Diabetes and Their Prevalence in Some African Cohorts
Prevalence52-54 Mode of evaluation Frequency of evaluation
Action if abnormal
Peripheral neuropathy
35%–70% Monofilament sensory testing of the feet. If a microfila-ment is not available, proprioception can be tested. Patients may also complain of neuropathic pain (burning, electrical sensations) in the feet
Once yearly Intensify treatment regimen if possible. Consider treating neuropathic pain with amitriptyline 25 to 100 mg per day orally. Shoes if needed. Counsel on foot protection
Foot ulcer 1.7%–10% Visual inspection, probe evaluation to rule out osteomyelitis
n/a Referral to district hospital for possible debridement and broad-spectrum antibiotics
Retinopathy or sight-threatening eye disease
5%–35% Fundoscopic evaluation or retinal photography
Once every 3 years, performed at a district hospital with an ophthalmic clinical o$cer. More frequent follow-up if estab- lished retinopathy.
Intensify treatment regimen if possible. Referral for evalua-tion at an ophthalmic center if needed for intervention
Cataracts 8.7%–25% Fundoscopic evaluation
Once every 3 years performed at a district hospital with an ophthalmic clinical o$cer
Referral for evaluation at an ophthalmic center for intervention
Albuminuria 18% Urine dipstick Every six months Intensify treatment regimen if possible. Add an ACE inhibitor (e.g., lisinopril, 5 mg per day orally)
Nephropathy 19%–34% Serum creatinine testing
Yearly Intensify treatment regimen if possible. Add an ACE inhibitor if no counterindica-tion (e.g., lisinopril, 5 mg per day orally)
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chapter!7 | diabetes 179
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7.7 Diabetes and Pregnancy
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180 chronic care integration for endemic non-communicable diseases
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7.8 Social Assistance and Community Health Workers
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chapter!7 | diabetes 181
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182 chronic care integration for endemic non-communicable diseases
Chapter 7!References
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chapter!7 | diabetes 183
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184 chronic care integration for endemic non-communicable diseases
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chapter!7 | diabetes 185
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chapter 8Hypertension
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188 chronic care integration for endemic non-communicable diseases
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-$#)49#'8&:4*'$.*&'%45"+4*'84$.#8'*7*#4:'$95'&"#2&62-&+P4#'+&*#*>'R&*#'87-4%#49*)&9')*'%4.$#)@4.7'*):-.4'#&'5)$A9&*4'$95'#%4$#'&9+4'$'*7*#4:''&6'+8%&9)+'+$%4'8$*'3449'4*#$3.)*845>'?9';<$95$C':&*#'87-4%#49*)&9')*':$9$A45'$#'#84'84$.#82+49#4%'.4@4.>'L#'#8)*'[email protected]'9"%*4*'<)#8'$'3$*)+'.4@4.'&6'#%$)9)9A'#%4$#'*):-.4'`S(*'$*'<4..'$*',?\'$95'H!')9')9#4A%$#45'+8%&9)+'+$%4'+.)9)+*>'H84*4'+.)9)+*'#495'#&'34'+.&*4%'#&'-$#)49#*='8&:4*'$95'+&*#'.4**'#&'%"9'#8$9'#8&*4'$#'5)*#%)+#'.4@4.>'G$#)49#*'<)#8'*4@4%4'.4@4.*'&6'87-4%#49*)&9'$%4'%464%%45'#&'#84'5)*#%)+#'8&*-)#$.'&%'5)*#%)+#2.4@4.'`S('+.)9)+'6&%':&%4'*-4+)$.)^45'#%4$#:49#>
chapter!8 | hypertension 189
?9'*&:4'*4##)9A*C'+&:3)9$#)&9'#$3.4#*'V-&.7-)..*X'+"%%49#.7'"954%'542@4.&-:49#':$7'&664%'$9T%':4$9*'&6'%45"+)9A'#%4$#:49#'+&*#*'$95')9+%4$*)9A'+&:-.)$9+4C'-$%#)+".$%.7'$:&9A'-$#)49#*'<8&'8$@4'-%4@)&"*.7'*"664%45'$':7&+$%5)$.')96$%+#)&9>/1'H84*4'+&:3)9$#)&9'#$3.4#*'&6#49':)E'$'87-4%#49*)&9'$A49#'<)#8'T%':45)+$#)&9*'*"+8'$*'$*-)%)9'$95',RT2S&L'%45"+#$*4')98)3)#&%*'V*#$#)9*X'#&'%45"+4'#84'%)*P'&6'@$*+".$%'4@49#*'$:&9A'87-4%#49*)@4*>',&<4@4%C'9&92)*+84:)+'4@49#*C'*"+8'$*'84$%#'6$).2"%4C'%49$.'6$)."%4C'$95'84:&%%8$A)+'*#%&P4C'+&9*#)#"#4'#84'-%):$%7'%)*P*'6$+45'37'87-4%#49*)@4'-$#)49#*')9'*4##)9A*'*"+8'$*'%"%$.';<$95$>//'[&%'#8)*'%4$*&9C'<4'5&'9&#'$5@&+$#4'#84'%&"#)94'"*4'&6'#84*4'+&:3)9$#)&9'&%'$5D"@$9#'#84%$-)4*'6&%':&*#'87-4%#49*)@4*')9'&"%'*4##)9A>';$#84%C'<4'%4*4%@4'#84'"*4'&6'$*-)%)9'6&%'87-4%#49*)@4'-$#)49#*'<)#8'5)$34#4*>'S"%2%49#.7C'<4'5&'9&#'%4+&::495'$55)9A'*#$#)9*'#&'#84';<$95$9'6&%:".$%7'6&%'%"%$.'6$+).)#)4*'34+$"*4'&6'#84'.&<')9+)549+4'&6'@$*+".$%'4@49#*>
8.1 Clinic and Community-Based Hypertension Screening
?9'%"%$.';<$95$C'87-4%#49*)&9C',?\C'$95'*#%4-#&+&++$.'-8$%79A)#)*'+&92*#)#"#4'#84':$)9'5%)@4%*'&6'+$%5)&@$*+".$%'%)*P>'!.&&5'-%4**"%4'*+%449)9A')9'$*7:-#&:$#)+')95)@)5"$.*'+$9'84.-')549#)67'-4&-.4'<)#8'87-4%#49*)&9'346&%4'#847'54@4.&-'4952&%A$9'+&:-.)+$#)&9*>'b6'+&"%*4C'*+%449)9A'<)..')549#)67'$'*-4+#%":'&6'8)A82'$95'.&<2%)*P'-$#)49#*>'L'*#%&9A'+8%&9)+'+$%4'
2)9A'#84'6%$A).4'84$.#8')96%$*#%"+#"%4'<)#8'-$#)49#*'<8&'8$@4'.&<'.4@4.*'&6'87-4%#49*)&9'#8$#'+&964%'.)##.4'%)*P'&6'4952&%A$9'5)*4$*4>'b"%'A&$.')9'*+%449)9A')*'#&')549#)67'8)A82%)*P')95)@)5"$.*'<8&'<&".5'9&#'T%<)*4'*44P'#%4$#:49#'346&%4'+&:-.)+$#)&9*'$%)*4>'
G1#)$.'&++$*)&9*'6&%'*+%449)9A')9+."54'&--&%#"9)*#)+'3.&&5'-%4*2*"%4':4$*"%4:49#'$#'$+"#4'+$%4'&%'&"#-$#)49#'54-$%#:49#'+.)9)+*'$95'*7*#4:$#)+'3.&&5'-%4**"%4':4$*"%4:49#'37'84$.#8'<&%P4%*')9'#84'+&::"9)#7>'?9'%4*&"%+42-&&%'*4##)9A*C'.$+P'&6'4O")-:49#C'#%$)9)9AC'$95'#):4'+$9'-&*4'3$%%)4%*'#&'):-.4:49#$#)&9'&6'%&"#)94'3.&&5'-%4**"%4':4$*"%4:49#'$#'$97'.4@4.'&6'#84'84$.#8'+$%4'*7*#4:>'T)@49'#84'+&:-4#2)9A'54:$95*'&9'+&::"9)#7'84$.#8'<&%P4%*C'<4'8$@4'6&+"*45')9)#)$..7'&9'*+%449)9A'$#'#84'84$.#82+49#4%'.4@4.>'_4'5&'#8)*')9'#84'+&9#4E#'&6'$+"#4'+$%4'-%&#&+&.*'6&%'#84'?9#4A%$#45'R$9$A4:49#'&6'L5".#'$95'L5&.4*+49#'?..94**>/J'L#'G?,2*"--&%#45'84$.#8'+49#4%*C'<4'49+&"%$A4'-%$+#)#)&94%*'#&':4$*"%4'#84'@)#$.'*)A9*C')9+."5)9A'3.&&5'-%4**"%4C'&6'4@4%7&94'<8&'-%4*49#*'<)#8'$'%&"#)94'+&:-.$)9#>'_4'"*4'@$.)5$#45'$"#&:$#)+'3.&&5'-%4**"%4':$+8)94*'$95'<4'P44-':$9"$.'+"66*'$@$).$3.4')9'+$*4'#84':$+8)94':$.6"9+#)&9*>'!$##4%)4*'&%'4.4+#%)+)#7'+$9'-&<4%'#84':$+8)94*>'L++"%$#4':4$*"%4:49#*'%4O")%4'#%$)9)9A')9'$--%&-%)$#4'+"66'*)^4*'$95'#84'-%&+"%4:49#'&6':$+8)94*'+&:-$#)3.4'<)#8'*:$..C'%4A".$%C'$95'.$%A4'$5".#'+"66*>
190 chronic care integration for endemic non-communicable diseases
L':&%4'&%'.4**')9#49*)@4'6$+).)#723$*45'*+%449)9A'$--%&$+8':$7'34'$-2-%&-%)$#4')9'T%'*4##)9A*>'L':&%4'%4*&"%+42)9#49*)@4'*#%$#4A7'<&".5'34'#&'8)%4'$9'4E#%$'+.4%P'#&':4$*"%4'@)#$.'*)A9*'&9'$..'-$#)49#*'$95'#&'#%)$A4'$++&%5)9A.7>'L'.4**')9#49*)@4'*#%$#4A7'<&".5'34'#&'&9.7':4$*"%4'3.&&5'-%4**"%4'&6'-$#)49#*'$3&@4'$'+4%#$)9'$A4'V4>A>C'K1X>'?9'*&:4'%4*&"%+42-&&%'*4##)9A*C'+&::"9)#723$*45'*+%449)9A':$7'34'$9'$--%&-%)$#4'$5D"9+#'#&'+.)9)+23$*45'3.&&5'-%4**"%4':4$*"%4:49#>'H8)*'*+%449)9A'+&".5'#$P4'-.$+4'$#'+8"%+84*'&%'*+8&&.*>'H84'"#).)#7'&6'+&::"9)#723$*45'*+%449)9A'54-495*')9'-$%#'&9'8&<'&6#49'$5".#*'@)*)#'84$.#8'6$+).)#)4*C'&%'<84#84%'#847'@)*)#'#84:'$#'$..>'L*':49#)&945'$3&@4C'+&:-4#)9A'54:$95*'6&%'*4%@)+4*'$#'#84'+&::"9)#7'.4@4.':$7':$P4'$+#)@4'54#4+#)&9'*#%$#4A)4*'$'.&<4%'-%)&%)#7')9'*&:4'+&9#4E#*>'PROTOCOL 8.1'&"#.)94*'$9'$--%&$+8'6&%'#8)*')9)#)$.'*+%449)9A'-%&+4**>'
L*':49#)&945'$3&@4C'87-4%#49*)&9')*'3'@4%7'+&::&9'$95'%4.$#)@4.7'*):-.4'#&'#%4$#>'R&*#'87-4%#49*)&9'-$#)49#*'+$9'34'#%4$#45'$#'#84'84$.#82+49#4%'.4@4.>',&<4@4%C'#84'*"3D4+#'34+&:4*':&%4'+&:-.4E'<849'&94'+&9*)54%*'$..'#84'5)*4$*4*'49+&:-$**45'37'#84'5)$A9&*)*'&6'87-4%#492*)&9>'L#'.&<'.4@4.*'&6'3.&&5'-%4**"%4'4.4@$#)&9C'%)*P'#&'#84'-$#)49#')*'@4%7'.&<'$95'%4O")%45'#%4$#:49#')*'$++&%5)9A.7':)9):$.>'L#'8)A84%'.4@4.*C'87-4%#49*)&9'34+&:4*'$'%$-)5.7'54$5.7'5)*4$*4C'%4O")%)9A'@4%7'$AA%4*2*)@4'#%4$#:49#>'?9'34#<449C'#84%4')*'$'%$9A4'&6':&%4'$95'.4**'*4@4%4'-%4*49#$#)&9*>'H8)*'84#4%&A494)#7'%4*".#*')9'<8$#':$7'$--4$%'#&'34'+&:-.4E'-%&#&+&.*'#&'4E-.$)9'#%4$#:49#'&6'$'*):-.4'-%&3.4:>',&<4@4%C'#8)*'$--%&$+8C'<4'34.)4@4C'%4-%4*49#*'&"%'34*#'$##4:-#'#&'$--%&-%)$#4.7'#$).&%'#%4$#:49#'$++&%5)9A'#&'%)*P'<8).4'$@&)5)9A'"994+4**$%7'#4*#)9A''&%'%464%%$.*>
Give nifedipine immediaterelease 10 mg PO x 1 ORcaptopril 25 mg PO x 1.
Consider Lasix 20 mg IV ORLasix 40 mg PO x 1 if di!culty
breathing
Transfer todistrict hospital
Danger signs: acute dyspnea, visual changes,
headache?
Address primary complaint
BP ≥ 180/110 mmHg
Address primary complaint
Lone Stage 1 140/90–160/100 mmHg WITHOUT high-risk features*
Return to acute care clinic in 12 months for BP
check. Counsel on reducing salt intake and
weight loss if appropriate.
Pregnant(all women
between 15 and49 should be
tested)
Stage 2 160/100–
180/110 mmHg
Return to acute care clinicin 6 months for BP check.Counsel on reducing saltintake and weight loss if
appropriate.* High-Risk Features: - Age ≥ 65 years- Known diabetes - Known renal failure- BMI ≥ 25 kg/m2- Tobacco smoking
≥ 6 mo trial of lifestyle
modification
Any patient with aroutine complaint
presenting to acutecare clinic
NO
YES
YES
NO
YES
NO
NO
NO
NO
YES YES
YES
YES
YES NO
NO
YES
BP ≥140/90 mmHgx2 at rest
Transient cause of HTN present
(e.g., pain, anxiety)
See management of HTN in pregnancy (Protocol 8.5)
Start two anti-hypertensives at initial dose, have follow-up in nearest
health center CCC in 1 week. Communicate appointment to
CCC nurse.
Stage 1 140/90–160/100
mmHg WITH 2 or more high-risk
features*
Refer to nearest CCC clinic in 1–4 weeks for evaluation
of HTN. Communicate appointment to CCC nurse.
BP = Blood pressureCCC = Chronic care clinicHTN = Hypertension
chapter!8 | hypertension 191
PROTOCOL 8.1 Initial Screening and Management of Hypertension in Acute Consultation Clinics
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192 chronic care integration for endemic non-communicable diseases
8.1.1 Evaluation of Blood Pressure in Acute Care ClinicsL+"#4'+$%4'+.)9)+)$9*'*8&".5'+84+P'#84'3.&&5'-%4**"%4'&6'$97'-$#)49#'-%4*49#)9A'<)#8'$'%&"#)94'+&:-.$)9#>'?6'#84'3.&&5'-%4**"%4':4$*"%4*'.4**'#8$9'/K1id1'::,AC'#84'+.)9)+)$9'-%&+445*'<)#8'#84'@)*)#'$*'"*"$.>'?6'#84'3.&&5'-%4**"%4':4$*"%4*'A%4$#4%'#8$9'/K1id1'::,AC'#84'+.)9)+)$9'%4+84+P*'#84'3.&&5'-%4**"%4C':$P)9A'*"%4'#8$#'#84'-$#)49#')*'$#'%4*#'$95'#8$#'#84'+"66'*)^4')*'$--%&-%)$#4>'
?6'3':4$*"%4:49#*'$%4'A%4$#4%'#8$9'/K1id1'::,AC'#84'+.)9)+)$9'
V4>A>C'-$)9'&%'$9E)4#7X>'
[4:$.4'-$#)49#*'34#<449'$A4'/0'$95'Kd'$%4'#4*#45'6&%'-%4A9$9+7>'[&%':$9$A4:49#'&6'87-4%#49*)&9')9'-%4A9$9+7C'*44'PROTOCOL 8.5'$95''SECTION 8.8>
H84'+.)9)+)$9'#849'4@$."$#4*'#84'-$#)49#=*'.4@4.'&6'87-4%#49*)&9'$95'#%4$#*'$++&%5)9A.7>'
8.1.2 Identification and Treatment of Emergency Conditions in Acute Consultation
%4+4)@4'6$*#2$+#)9A'$9#)287-4%#49*)@4'#84%$-7'VTABLE 8.4X'$95'$%4''#%$9*64%%45'#&'#84'5)*#%)+#'8&*-)#$.'6&%')9-$#)49#':$9$A4:49#''V*44'SECTION 8.4X>'
8.1.3 Treatment of Asymptomatic Hypertension by Disease Classification
L*7:-#&:$#)+'*#$A4'B'87-4%#49*)&9'-$#)49#*'$%4'*#$%#45'&9'#<&'$9#)287-4%#49*)@4*'$95'A)@49'$'6&..&<2"-'$--&)9#:49#')9'#84'94$%4*#'84$.#8'+49#4%')9#4A%$#45'+8%&9)+'+$%4'+.)9)+'<)#8)9'#84'94E#'<44P>'SECTION 8.3'5)*+"**4*'&"%'%$#)&9$.4'6&%'5%"A'+8&)+4*C'$95'TABLE 8.2'$95'TABLE 8.3'&"#.)94')9)#)$.'$9#)87-4%#49*)@4'#%4$#:49#'6&%'*#$3.4'-$#)49#*>
?9'$..'+$*4*'&6'%464%%$.'#&'#84'84$.#8'+49#4%')9#4A%$#45'+8%&9)+'+$%4'+.)9)+C'#84'$+"#4'+$%4'+.)9)+)$9':"*#'+&::"9)+$#4'#84'%464%%$.'#&'#84'+8%&9)+'+$%4'+.)9)+)$9C'4)#84%'#8%&"A8'$'*8$%45'<%)##49'-$#)49#'.&A'3&&P'$95i&%'#8%&"A8'#84'4.4+#%&9)+':45)+$.'%4+&%5'*7*#4:>
8.1.3.1 Stage 2 Hypertension (160/100–180/110 mmHg) G$#)49#*'<)#8'*#$A4'J'87-4%#49*)&9'V/Z1i/11k/g1i//1'::,AX'$%4'9&#'*#$%#45'&9'$97':45)+$#)&9*')9'#84'$+"#4'*4##)9A>'H847'$%4'%464%%45'#&'#84'94$%4*#'84$.#8'+49#4%')9#4A%$#45'+8%&9)+'+$%4'+.)9)+')9'$'9&92"%A49#'
)9)#)$#)&9'&6'#84%$-7')9'-$#)49#*'$#'.&<'%)*P'6&%'*8&%#2#4%:'+&:-.)+$#)&9*>'
chapter!8 | hypertension 193
8.1.3.2 Stage 1 Hypertension (140/90–160/100) with High-Risk Features G$#)49#*'<)#8'*#$A4'/'87-4%#49*)&9'$%4'4@$."$#45'6&%'8)A82%)*P'64$#"%4*'#8$#':$7'<$%%$9#':&%4'$AA%4**)@4'#%4$#:49#'&6'3.&&5'-%4**"%4>',)A82%)*P'64$#"%4*')9+."54'P9&<9'5)$34#4*'&%'%49$.'6$)."%4C'&@4%<4)A8#'V!R?'
TABLE 8.1X>'S.)9)+)$9*'
+&%%4*-&95)9A'!R?'6&%'$..'-$#)49#*'$*'-$%#'&6'$5".#':$.9"#%)#)&9'*+%4492)9A')9'$+"#4'+$%4>'?9'$55)#)&9C'-$#)49#*'$%4'$*P45'$3&"#'#&3$++&'"*4'$95'-%4@)&"*'5)$A9&*)*'&6'5)$34#4*>'?96&%:$#)&9'&9'-%)&%'5)$A9&*4*'+$9'&6#49'34'&3#$)945'6%&:'#84'-$#)49#2+$%%)45':45)+$.'%4+&%5>'
U$+8'%)*P'6$+#&%'4$%9*'$'-$#)49#'$'+4%#$)9'9":34%'&6'-&)9#*>';)*P'6$+#&%*'*"+8'$*'5)$34#4*'$95'%49$.'6$)."%4'+&964%':&%4'%)*P'#8$9'#84'T%'%)*P'6$+#&%*'$95'$%4'<4)A8#45':&%4'84$@).7>'G$#)49#*'<)#8'J'&%':&%4'-&)9#*'$%4'+&9*)54%45'8)A8'%)*P'$95'$%4'#%4$#45':&%4'$AA%4**)@4.7>
TABLE 8.1 High-Risk Features in Hypertension
High-risk feature Points
Diagnosis of diabetes 2
Diagnosis of renal failure (creatinine 1) 2
Age 65 years 1
BMI 25 kg/m2 1
Tobacco smoking 1
A total of 2 or more points is considered high risk and warrants more aggressive treatment.
G$#)49#*'<)#8'*#$A4'/'87-4%#49*)&9'V/K1id1k/Z1i/11'::,AX'<8&'8$@4':&%4'#8$9'#<&'8)A82%)*P'64$#"%4*'$%4'+&"9*4.45'&9'%45"+)9A'*$.#')9#$P4'
%4#"%9'#&'$+"#4'+$%4')9'*)E':&9#8*>'?6'*#)..'87-4%#49*)@4'$6#4%'$'*)E2:&9#8'
)9#4A%$#45'+8%&9)+'+$%4'+.)9)+'<)#8)9'/'#&'K'<44P*>'H84'+.)9)+)$9'5&4*'9&#')9)#)$#4'$9#)287-4%#49*)@4'#84%$-7')9'#84'$+"#4'+$%4'*4##)9A>
8.1.3.3 Low-Risk Stage 1 Hypertension G$#)49#*'<)#8'*#$A4'/'87-4%#49*)&9'$95'64<4%'#8$9'#<&'%)*P'-&)9#*'$%4'$#'.&<'%)*P'&6'+&:-.)+$#)&9*'6%&:'#84)%'87-4%#49*)&9>'[&%'#8)*'%4$*&9C'<4'$5@&+$#4'54.$7)9A'-8$%:&+&.&A)+'#%4$#:49#'$95i&%'%464%%$.'#&')9#4A%$#245'+8%&9)+'+$%4'+.)9)+*'6&%'#84*4'-$#)49#*>'H84*4'-$#)49#*'$%4'+&"9*4.45'#&'$@&)5'$5545'*$.#'$95')9*#%"+#45'#&'%4#"%9'#&'#84'$+"#4'+$%4'+.)9)+')9'&94'74$%'6&%'$'%4-4$#'3.&&5'-%4**"%4':4$*"%4:49#>'G$#)49#*'<)#8'$'!R?'
YES
YES
YES
YES
YES
NO
NO
YES
NO
YES
YES
NO
NO
YES YES
NO
NO
YES
NO
BP ≥
180/
110
mm
Hg
AN
Dda
nger
sign
s:
acut
e dy
spne
a, v
isual
cha
nges
, he
adac
he?
Man
age
as h
yper
tens
ive
emer
genc
y(S
ectio
n 8.
4, T
able
8.4
)
Tran
sfer
to
dist
rict h
ospi
tal
See
man
agem
ent o
f hy
pert
ensio
n in
pr
egna
ncy
Patie
nt
refe
rred
to
heal
th c
ente
r CC
C fo
r HTN
Preg
nant
?(w
omen
bet
wee
n 15
and
49
shou
ld b
e te
sted
)
Com
plet
e in
take
form
, ev
alua
te fo
r com
plic
atin
g/co
mor
bid
fact
ors
Sign
s of
hear
t fai
lure
(e
dem
a, d
yspn
ea)
Refe
r to
NCD
cl
inic
for
susp
ecte
d he
art
failu
re(P
roto
col 4
.1)
(Pro
toco
l 8.5
)
Mee
ts cr
iteria
for C
CC re
ferr
al:
(1) B
P ≥
160/
100
mH
g O
R (2
) BP ≥
140/
90 m
mH
g A
ND
≥
2 h
igh
risk
poin
ts* A
ND
fa
iled
tria
l of l
ifest
yle
mod
ifica
tion
Refe
r pat
ient
bac
k to
ur
gent
car
e se
tting
for
BP
rech
eck
in 6
–12
mon
ths
Stag
e 1
(140
/90–
160/
100
mm
Hg)
Stag
e 3
≥ 18
0/11
0m
mH
g
Stag
e 2
160/
100–
18
0/11
0 m
mH
g
Eval
uate
hyp
erte
nsio
n st
age
Star
t one
dru
g at
low
est d
ose.
Ret
urn
to
heal
th c
ente
r CC
C in
3
mon
ths
Chec
k cr
eatin
ine
and
prio
ritiz
e A
CE-I
if no
t co
ntra
indi
cate
d (i.
e.,
preg
nanc
y or
cre
atin
ine ≥
200
µmol
/L)
Dia
betic
Chec
k ur
ine
dips
tick
≥ 2
+ pr
otei
nuria
Refe
r to
dist
rict-
leve
l N
CD c
linic
in 1–
2 w
eeks
See
man
agem
ent o
f di
abet
es
(Cha
pter
7)
BP
goal
will
be
≤ 13
0/80
mm
Hg
NO
BMI ≥
25?
Any
gly
cosu
ria
Chec
k a
confi
rmat
ory
test
fo
r dia
bete
s (f
astin
g bl
ood
gluc
ose
or
hem
oglo
bin
A1C
). If
diab
etes
co
nfirm
ed, B
P go
al w
ill b
e≤
130/
80 m
mH
g(C
hapt
er 7
)
BP =
Blo
od p
ress
ure
CCC
= Ch
roni
c ca
re c
linic
HTN
= H
yper
tens
ion
* Hig
h-Ri
sk F
eatu
res:
D
iabe
tes –
2 p
oint
s R
enal
failu
re –
2 p
oint
s P
rote
inur
ia –
2 p
oint
s T
obac
co sm
okin
g –
1 poi
nt B
MI ≥
25
– 1 p
oint
Age
≥ 6
5 ye
ars –
1 po
int
1. If ≤
40,
che
ck fo
r cau
ses o
f se
cond
ary
HTN
2. St
art t
wo
drug
s at l
owes
t do
se3.
Ret
urn
to h
ealth
cen
ter C
CC
in 3
mon
ths.
In d
istr
ict N
CD cl
inic
:1.
Eval
uate
for s
igns
of h
eart
failu
re. I
f pre
sent
per
form
an
ech
o2.
Che
ck c
reat
inin
e3.
If ≤
40,
con
sider
che
ckin
g fo
r oth
er c
ause
s of
seco
ndar
y H
TN4.
Sta
rt tw
o dr
ugs a
t low
est d
ose.
5. If
no
rena
l or h
eart
failu
re, r
efer
bac
k to
hea
lth c
ente
r CC
C fo
r visi
t in
1–2
wee
ks. O
ther
wise
, ret
urn
to
dist
rict N
CD c
linic
in 1–
2 w
eeks
.
194 chronic care integration for endemic non-communicable diseases
8.2 Initial Management of Newly Referred Hypertension Cases in Health Center Integrated Chronic Care Clinics
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PROTOCOL 8.2 Initial Management of Newly Referred Hypertension Cases in Health Center Integrated Chronic Care Clinics
chapter!8 | hypertension 195
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8.2.1 Identification and Treatment of Emergency Conditions in the Health Center Integrated Chronic Care Clinic
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8.2.2 Evaluation for Comorbid Conditions in the Health Center Integrated Chronic Care Clinic
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196 chronic care integration for endemic non-communicable diseases
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CHAPTER 7'6&%'6"%#84%'54#$).'&9':$9$A4:49#'&6'5)$34#)+'-$#)49#*>'
8.2.3 Evaluation of Hypertension Stage in the Health Center Integrated Chronic Care Clinic
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*)&9'*4@4%)#7>'G$#)49#*'<)#8'8)A84%'54A%44*'&6'87-4%#49*)&9'$95i&%'+&:&%3)5'6$+#&%*'%4+4)@4':&%4'$AA%4**)@4'#%4$#:49#'$++&%5)9A'#&'#84'8)A82%)*PC'-&)9#23$*45'*7*#4:'$3&@4'VTABLE 8.1X>'TABLE 8.22&"#.)94*'#84')9)#)$.'#%4$#:49#'*#%$#4A7'3$*45'&9'%)*P'$95'87-4%#49*)&9'+$#4A&%7>'SECTION 8.3'$95'TABLE 8.3'&"#.)94'$'*#4-2372*#4-'$--%&$+8'#&'$9#)87-4%2#49*)@4':45)+$#)&9'*4.4+#)&9>'
8.2.3.1 Treatment of Higher-Risk Stage 1 Hypertension in the Health Center Integrated Chronic Care Clinic
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8.2.3.2 Evaluation of Proteinuria in Stage 2 and Stage 3 Hypertension in the Health Center Integrated Chronic Care Clinic
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8.2.3.3 Evaluation of Glycosuria in Stage 2 and Stage 3 Hypertension or Overweight Patients in the Health Center Integrated Chronic Care Clinic
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2
chapter!8 | hypertension 197
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8.2.3.4 Treatment of Stage 2 Hypertension in the Health Center Integrated Chronic Care Clinic
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8.2.3.5 Treatment of Asymptomatic Stage 3 Hypertension in the Health Center Integrated Chronic Care Clinic
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198 chronic care integration for endemic non-communicable diseases
TABLE 8.2 Initiation of Hypertension Treatment According to Stage and Risk Factors
Stage Blood pressure range
Treatment Clinic follow-up
Stage 1AND
1 high risk point (TABLE 8.1)
140/90–160/100 mmHg
Do not start medications.Counsel on salt intake and weight loss if indicated.
12 months in acute care
Stage 1 AND
2 high risk points (TABLE 8.1)ANDNo trial of lifestyle modification
140/90–160/100 mmHg
Do not start medications.Counsel on salt intake and weight loss if indicated.
6 months in acute care
Stage 1 AND
2 high risk points (TABLE 8.1)ANDFailed 6-month trial of lifestyle modification
140/90–160/100 mmHg
Start first-line medication at lowest dose
3 months in health center integrated chronic care clinic
Stage 2 160/100–180/110 mmHg
Start first- and second-line medications at lowest dose
3 months in health center integrated chronic care clinic
Stage 3WITHOUTDanger signs*
180/110+ mmHg Start first- and second-line medications at lowest dose
1–2 weeks in district level NCD clinic
Stage 3WITHDanger signs*
180/110+ mmHg Initiate therapy listed in TABLE 8.4. Transfer to district hospital for inpatient management
* Danger signs include acute dyspnea, visual changes, headaches.
8.3 Recommended Hypertension Medications and Dosing
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chapter!8 | hypertension 199
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Z!*#%B=*&02"-0&81+'?9':$97'-$#)49#*C'#<&':45)+$#)&9*'4@49'$#'#84)%':$E):":'5&*4':$7'9&#'34'49&"A8'#&'$+8)4@4'3.&&5'-%4**"%4'+&9#%&.>'H8)*')*'-$%#)+".$%.7'#%"4'6&%'-$#)49#*'<)#8'*#$A4'B'87-4%#49*)&9>'LSU')928)3)#&%*'V.)*)9&-%).'&%'+$-#&-%).X'$%4'#84'-%464%%45'#8)%52.)94'$A49#'$6#4%'#84':$E):":'5&*4'&6'875%&+8.&%#8)$^)54'$95'$:.&5)-)94'8$@4'3449'%4$+845>'LSU')98)3)#&%*'$%4'+&9#%$)95)+$#45')9'-%4A9$9+7'$95'*4@4%4'
Y,<#8!B=*&02"-0&81+'Y&:4'-$#)49#*':$7'8$@4'87-4%#49*)&9'#8$#')*'-$%#)+".$%.7'%4*)*#$9#'#&'3.&&5'-%4**"%4':45)+$#)&9*>'[&"%':45)+$#)&9*'6&%'87-4%#49*)&9':$7'34'944545>'?9'A494%$.C'$#49&.&.')*'#84'6&"%#82.)94'$9#)87-4%#49*)@4'&6'+8&)+4>'L.#8&"A8')#')*')94E-49*)@4C'#84'4664+#)@494**'&6'$#49&.&.')9'%45"+)9A'+49#%$.'3.&&5'-%4**"%4'$95'-%4@49#)9A'$5@4%*4'+$%5)&@$*+".$%'&"#+&:4*'8$*'3449'+$..45')9#&'O"4*#)&9>/B
Y*C8!B=*&02"-0&81+'H84*4':45)+$#)&9*'*8&".5'%$%4.7'34'"*45'6&%'87-4%22
64+#)@4C':4#87.5&-$'$95'875%$.$^)94'%4O")%4':".#)-.4'5&*4*'-4%'5$7'$95'
#84*4':45)+$#)&9*'$%4'6%4O"49#.7'#84':&*#'$@$).$3.4')9'%4*&"%+42-&&%'*4##)9A*'5"4'#&'#84)%'*$64#7')9'-%4A9$9+7'V*44'SECTION 8.8X>
200 chronic care integration for endemic non-communicable diseases
TABLE 8.3 Recommended Hypertension Medications and Dosing for Most Adult Patients
First-line drug Starting dose Increase dose by
Maximum dose
Notes
Hydrochlorothiazide 12.5 mg 1x/day 12.5 mg 1x/day 25 mg 1x/day Can cause hypokalemiaNot e#ective in the setting of severe renal failure (creatinine 300 µmol/L)
Second-line drug Starting dose Increase dose by
Maximum dose
Notes
Amlodipine 5 mg 1x/day 5 mg 1x/day 10 mg 1x/day Can cause lower-extremity edema
Third-line drug Starting Dose Increase dose by
Maximum dose
Notes
Lisinopril 5 mg 1x/day 5 mg 1x/day 20 mg 1x/day Contraindicated in pregnancy and advanced renal failure (creatinine 200 µmol/L)Can cause cough
Captopril 12.5 mg 3x/day 12.5 mg 3x/day 50 mg 3x/day
Fourth-line drug Starting dose Increase dose by
Maximum dose
Notes
Atenolol 25 mg 1x/day 25 mg 1x/day 50 mg 1x/day Contraindicated if heart rate 55 bpmUse with caution in renal failure, since atenolol is renally cleared
Fifth-line drug Starting dose Increase dose by
Maximum dose
Notes
Hydralazine 25 mg 3x/day 25 mg 3x/day 50 mg 3x/day Safe in pregnancyHeadache common side e#ect of hydralazine
Methyldopa 250 mg 2x/day 250 mg 2x/day 500 mg 2x/day Safe in pregnancy
8.4 Recognition and Management of Hypertensive Emergency
L+"#4'%)*4*')9'3.&&5'-%4**"%4'+$9'%4*".#')9'4952&%A$9'5$:$A4')9'$':$#2#4%'&6'8&"%*>'H84*4'87-4%#49*)@4'4:4%A49+)4*'"*"$..7'&++"%'$#'3.&&5'-%4**"%4*'$3&@4'/g1'::,A'*7*#&.)+'&%'//1'::,A'5)$*#&.)+>'Y)A9*'&6'$'87-4%#49*)@4'4:4%A49+7')9+."54'84$5$+84'$95'3."%%45'@)*)&9'+$"*45'37')9+%4$*45')9#%$+%$9)$.'-%4**"%4C'57*-94$'+$"*45'37'$9'$+"#4'*#)6649)9A'
-$)9'+$"*45'37')9D"%7'#&'#84'P)5947*>'
G$#)49#*'%4-&%#)9A'*"+8'*7:-#&:*'<)#8'3.&&5'-%4**"%4'&@4%'/g1i//1'::,A'*8&".5'34'#%4$#45')::45)$#4.7'<)#8':45)+$#)&9*'#&'.&<4%'#84)%'
3&57'$5D"*#*'#&'87-4%#49*)&9'&@4%'#):4C'.&<4%)9A'3.&&5'-%4**"%4'#&&'
chapter!8 | hypertension 201
2%$#)&9>'TABLE 8.4'.)*#*':45)+$#)&9*'%4+&::49545'6&%'$+"#4':$9$A4:49#'&6'87-4%#49*)@4'4:4%A49+7>
L..'-$#)49#*'<)#8'*"*-4+#45'87-4%#49*)@4'4:4%A49+7'*8&".5'34'#%$9*264%%45'#&'#84'94$%4*#'5)*#%)+#'8&*-)#$.'6&%')9-$#)49#':$9$A4:49#>
TABLE 8.4 Recommended Medications for Management of Hypertensive Emergency (Adult Dosing)
Medication Dosing Notes
Nifedipine (immediate release)
10 mg orally
Captopril 25 mg orally Contraindicated in pregnancy and severe renal failure (Cr 200 µmol/dL)
Hydralazine 25 mg orally
Furosemide 40 mg orally or 20 mg IV If evidence of pulmonary congestion
8.5 Renal Dysfunction in Hypertension
,7-4%#49*)&9'$95'%49$.'57*6"9+#)&9'&6#49'+&4E)*#>'_849'#84'P)5947*'
:$7')9+%4$*4>',7-4%#49*)&9':$7'$.*&'.4$5'#&'%49$.'6$)."%4'37'-"##)9A'2
*"%4'<)#8'$9#)87-4%#49*)@4*'+$9'*.&<'#84'-%&A%4**)&9'&6'%49$.'5)*4$*4>',&<4@4%C'+4%#$)9':45)+$#)&9*'$%4'4)#84%'5$9A4%&"*'&%'9&'.&9A4%'<&%P'<4..')9'#84'*4##)9A'&6'%49$.'6$)."%4C'$*'4E-.$)945'34.&<>
202 chronic care integration for endemic non-communicable diseases
TABLE 8.5 Hypertension Medications and Dosing in Setting of Proteinuria or Mild Renal Failure (Creatinine 100–200 !mol/L)
First-line drug Starting dose Increase dose by
Maximum dose
Notes
Lisinopril 5 mg 1x/day 5 mg 1x/day 20 mg 1x/day Contraindicated in pregnancy and advanced renal failure (creatinine 200 µmol)Can cause cough
Captopril 12.5 mg 3x/day 12.5 mg 3x/day 50 mg 3x/day
Second-line drug Starting dose Increase dose by
Maximum dose
Notes
Hydrochlorothiazide 12.5 mg 1x/day 12.5 mg 1x/day 25 mg 1x/day Can cause hypokalemia Not e#ective in the setting of severe renal failure (creatinine
300 µmol)
Third-line drug Starting dose Increase dose by
Maximum dose
Notes
Amlodipine 5 mg 1x/day 5 mg 1x/day 10 mg 1x/day Can cause lower-extremity edema
Fourth-line drug Starting dose Increase dose by
Maximum dose
Notes
Atenolol 25 mg 1x/day 25 mg 1x/day 50 mg 1x/day Contraindicated if heart rate 55 bpm
Use with caution in renal failure as is renally cleared
Fifth-line drug Starting dose Increase dose by
Maximum dose
Notes
Hydralazine 25 mg 3x/day 25 mg 3x/day 50 mg 3x/day Safe in pregnancy. Headache common side e#ect
Methyldopa 250 mg 2x/day 250 mg 2x/day 500 mg 2x/day Safe in pregnancy
8.5.1 Proteinuria or Mild Renal Failure (Creatinine between 100–200 !mol/L)
G%)9"%)$')*'$9'4$%.7'*)A9'&6'%49$.'57*6"9+#)&9>'R).5'%49$.'6$)."%4')*'#7-)+$..7'-%4*49#'$#'+%4$#)9)94'.4@4.*'34#<449'/11'$95'J11'n:&.iF>'LSU')98)3)#&%*'84.-'54+%4$*4'-%)9"%)$'$95'-%4@49#'6"%#84%'%49$.'5$:$A4'
$..'-$#)49#*'<)#8'-%)9"%)$'&%':).5'%49$.'6$)."%4'"9.4**'+&9#%$)95)+$2
>
chapter!8 | hypertension 203
TABLE 8.6 Recommended Hypertension Medications and Dosing in Setting of Severe Renal Failure (Creatinine 200 !mol/L)
First-line drug Starting dose Increase dose by
Maximum dose
Notes
If Cr 300 µmol/L
Hydrochlorothiazide 12.5 mg 1x/day 12.5 mg 1x/day 25 mg 1x/day Can cause hypokalemia
If Cr 300 µmol/L
Furosemide 20 mg 1x/day 20 mg 1x/day 40 mg 1x/day
Second-line drug Starting dose Increase dose by
Maximum dose
Notes
Amlodipine 5 mg 1x/day 5 mg 1x/day 10 mg 1x/day Can cause lower-extremity edema
Third-line drug Starting dose Increase dose by
Maximum dose
Notes
Atenolol 25 mg 1x/day 25 mg 1x/day 100 mg 1x/day Contraindicated if heart rate
55 bpmUse with caution in renal failure
Fourth-line drug Starting dose Increase dose by
Maximum dose
Notes
Hydralazine 25 mg 3x/day 25 mg 3x/day 50 mg 3x/day Safe in pregnancyHeadache common side e#ect
Methyldopa 250 mg 2x/day 250 mg 2x/day 500 mg 2x/day Safe in pregnancy
,&<4@4%C')9'#84'+$*4'&6'4@49':&%4'*4@4%4'%49$.'57*6"9+#)&9'V+%4$#)9)94''
#8)*'*+49$%)&C'$'.&&-'5)"%4#)+'V6"%&*4:)54X'*8&".5'34'*"3*#)#"#45'$*'#84'
$%4'$.*&'*$64')9'%49$.'6$)."%4C'$95'*8&".5'34'#84'94E#'+8&)+4>'L#49&.&.'+$9'$.*&'34'"*45C'3"#'#84'5&*4'*8&".5'9&#'4E+445'01':Ai5$7')9'#84*4'-$#)49#*>'H8)*')*'34+$"*4'$#49&.&.')*'4E+%4#45'37'#84'P)5947*>'LSU')98)3)2#&%*'$95'*-)%&9&.$+#&94'*8&".5'34'$@&)545'5"4'#&'#84'%)*P'&6'87-4%P$.42:)$>'!4+$"*4'#84*4'-$#)49#*'$%4'$#'%)*P'6&%':".#)-.4'+&:-.)+$#)&9*C'#847'*8&".5'34'6&..&<45'$#'#84'.4@4.'&6'#84'5)*#%)+#'8&*-)#$.>
Patient ≤ 40 years old and SBP ≥ 160 mmHg and DBP ≥ 100 mmHg
Check creatinine and potassium(if available)
Creatinine ≥ 200 µmol/L Hypertension likely secondary to renal
failure. See Section 8.5
Evaluate for other causes of secondary hypertension and refer to endocrinologist1. Cushingnoid features2. Signs of hyperaldosteronism (low potassium)3. Signs of coarction (delayed or absent femoral pulse, SBP in legs 40 mmHg ≤ than in arms)4. Symptoms of pheochromocytoma (periodic episodes of hypertension, anxiety, tachycardia, diaphoresis)5. Signs of renal artery stenosis (abdominal bruit, creatinine more than doubles after starting ACE-I)
NO
YES
204 chronic care integration for endemic non-communicable diseases
8.6 Evaluation and Management of Hypertension in Younger Patients
R&*#'4**49#)$.'87-4%#49*)&9'<)..'&++"%')9'-$#)49#*'&@4%'#84'$A4'&6'K1>'?6'$'-$#)49#'-%4*49#*'<)#8':&54%$#4'#&'*4@4%4'87-4%#49*)&9'$#'$'7&"9A4%'$A4C'*4+&95$%7'+$"*4*'&6'87-4%#49*)&9'$%4':&%4'.)P4.7'#&'34'$'+$"*4'V*44'TABLE 8.7X>'PROTOCOL 8.3'&"#.)94*'$'5)$A9&*#)+'$--%&$+8'#&'#84*4'-$#)49#*>'
PROTOCOL 8.3 Initial Diagnosis and Management of Suspected Secondary Hypertension
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
TABLE 8.7 Causes of Secondary Hypertension
Cause Findings Management
Renal failure Elevated creatinine ( 200) See SECTION 8.5
Cushing’s syndrome (hypercortisolism)
Truncal obesity, round face, extremity wasting, hypokalemia
Refer to tertiary referral center for endocrinology consultation
Hyperaldosteronism Hypokalemia Refer to tertiary referral center for endocrinology consultation
Pheochromocytoma Periodic episodes of hypertension, anxiety, tachycardia, diaphoresis
Refer to tertiary referral center for endocrinology consultation
Coarctation Delayed or absent femoral pulse; SBP in legs 40 mmHg than SBP in arms
Refer to tertiary referral center for echocardiography and cardiology consultation
Renal artery stenosis Abdominal bruit; creatinine more than doubles after starting ACE inhibitor
Refer to tertiary referral center for renal ultrasound and nephrology consultation
YES
YES
NO
NO
NO
NO
YES
YES
YES
NO
NO
YES
YES
YES
NO
YES
NO
BP ≥ 180/110 mmHg AND
danger signs: acute dyspnea, visual changes,
headache?
Treat as hypertensive emergency (Section 8.4 and Table 8.4)
Transfer to district hospital
See management of hypertension in pregnancy
(Section 8.8)
Patient on medications for hypertension
Pregnant?(Test women 15–49 if
suspected)
Complete follow-up form
Controlled (BP ≤ 140/90
mmHg)
Stage 3≥ 180/110
mmHg
Stage 2160/100 –
180/110 mmHg
Evaluate hypertension stage
Continue current therapy.Return to health center CCC in
3–12 months depending on health center refill mechanism
Check creatinine and prioritize ACE inhibitor if not contraindicated
(i.e., pregnancy or creatinine ≥ 200 µmol/L)
Urine dipstick checked in past
year?
Start or increase two drugs by one interval. Return to health center CCC in 3 months
Start or increase two drugs by one interval.Consider assigning a community health worker Refer to district level NCD clinic in 1–2 weeks
Stage 1BP 140/90–
160/100 mmHgStart or increase one drug by one interval. Return to health center CCC in 3 months
Check urine dipstick ≥ 2+ proteinuria
Any glycosuriaCheck a confirmatory test
for diabetes (fasting blood glucose or
hemoglobin A1C)
BP = Blood pressureCCC = Chronic care clinic
chapter!8 | hypertension 205
8.7 Follow-Up Treatment for Hypertension
PROTOCOL 8.4'&"#.)94*'$9'$--%&$+8'#&'&9A&)9A':$9$A4:49#'&6'-$#)49#*'<8&'$%4'6&..&<45')9'#84'+8%&9)+'+$%4'+.)9)+*'6&%'87-4%#49*)&9>'
PROTOCOL 8.4 Follow-Up Visit for Chronic Hypertension in Health Center Integrated Chronic Care Clinic
206 chronic care integration for endemic non-communicable diseases
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8.7.1 Management of Well-Controlled Hypertension on Follow-UpG$#)49#*'<)#8'<4..2+&9#%&..45'87-4%#49*)&9'*8&".5'8$@4'#84)%'+"%%49#'%4A):49'+&9#)9"45>'H84*4'-$#)49#*'5&'9&#'9445'#&'34'*449')9'#84'+.)9)+'
:".#)2:&9#8'*"--.)4*'&6':45)+$#)&9'<)#8&"#'+$"*)9A'*#&+P2&"#*>'H84%426&%4C'#84'#):4'34#<449'+.)9)+'@)*)#*'<)..'54-495':&*#.7'&9'#84'5)*-49*)9A'
8.7.2 Follow-Up of Stage 1 Hypertension[&%'-$#)49#*'<)#8'*#$A4'/'87-4%#49*)&9'V34#<449'/K1id1'$95'/Z1i/11'::,AXC'#84'3.&&5'-%4**"%4':45)+$#)&9'*8&".5'34')9+%4$*45'37'&94')9#4%@$.'V*44'TABLE 8.3X>'
8.7.3 Follow-Up of Stage 2 HypertensionG$#)49#*'<)#8'*#$A4'J'87-4%#49*)&9'V34#<449'/Z1i/11'$95'/g1i//1'::,AX'*8&".5'8$@4'#<&':45)+$#)&9*'*#$%#45'&%')9+%4$*45'37'&94')9#4%2@$.'V*44'TABLE 8.3X>'G$#)49#*')9'#8)*'+$#4A&%7'*8&".5'8$@4'$'"%)94'5)-*#)+P'+84+P45'&9+4'$'74$%>'G$#)49#*'<)#8'-%)9"%)$'$95'$'+%4$#)9)94'.4@4.''
2
8.7.4 Follow-Up of Stage 3 HypertensionG$#)49#*'<)#8'*#$A4'B'87-4%#49*)&9'VA%4$#4%'#8$9'/g1i//1'::,AX'*8&".5'$.*&'8$@4'#<&':45)+$#)&9*'*#$%#45'&%')9+%4$*45'37'&94')9#4%@$.'V*44'TABLE 8.3X>'G$#)49#*')9'#8)*'+$#4A&%7'*8&".5'$.*&'8$@4'$'"%)94'5)-*#)+P'+84+P45'&9+4'$'74$%C'$95'-$#)49#*'<)#8'-%)9"%)$'*8&".5'8$@4'$9'LSU')98)3)#&%'*#$%#45'$*'-$%#'&6'#84)%'%4A):49>'G$#)49#*'<)#8'$97'A.7+&*"%)$'
9445'+.&*4%'6&..&<2"-'$95'*8&".5'34'A)@49'$9'$--&)9#:49#'<)#8)9'/kJ'
<&%P4%'#&'-%&@)54'*"--&%#'$95'49*"%4'A&&5':45)+$#)&9'$584%49+4>'
8.8 Hypertension in Pregnancy
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chapter!8 | hypertension 207
*"3D4+#C'$95':&*#'+"%%49#'A")54.)94*'%4.7'&9'4E-4%#'&-)9)&9'%$#84%'#8$9'<4..254*)A945'*#"5)4*>
,7-4%#49*)&9')9'-%4A9$9+7'+$9'34'-%424E)*#)9A'V+8%&9)+X'&%'+$"*45'37'#84'-%4A9$9+7')#*4.6>/0'?9'9&%:$.'-%4A9$9+7C'3.&&5'-%4**"%4'#495*'#&'6$..>'?9'#8)*'+&9#4E#C'3.&&5'-%4**"%4*'$3&@4'/K1'::,A'*7*#&.)+'&%'d1'5)$*#&.)+'$%4'+&9*)54%45'4.4@$#45h'3.&&5'-%4**"%4*'A%4$#4%'#8$9'/Z1'::,A'*7*2#&.)+'&%'//1'::,A'5)$*#&.)+'$%4'+&9*)54%45'*4@4%4.7'4.4@$#45>/Z
TABLE 8.8'&"#.)94*'#84'+$#4A&%)4*'&6'87-4%#49*)@4'5)*&%54%*')9'-%4A9$9+7>'H%4$#:49#'&6'87-4%#49*)&9'5&4*'9&#'$.#4%'#84'+&"%*4'&6'87-4%#49*)@4'5)*&%54%*'&6'-%4A9$9+7C'A)@49'#8$#'$9#)287-4%#49*)@4':45)+$#)&9*'5&'9&#'$664+#'#84'"954%.7)9A'-$#8&-87*)&.&A7'&6'#84'5)*4$*4>'H84'&94'-%&@49'
/Z'G%&@)5)9A':$A94*)":'#&'-$#)49#*'<)#8'*4@4%4'-%44+.$:-*)$'8$*'3449'*8&<9'#&'54+%4$*4'#84'%)*P'&6'*4)^"%4*>
+&..4+#45'&@4%'$'JK28&"%'-4%)&5>';$95&:'-%)92#&2+%4$#)9)94':4$2
<)542*+$.4'"*4')9'*4##)9A*'<)#8&"#'<4..254@4.&-45'.$3')96%$*#%"+#"%4>'a%)94'5)-*#)+P*'$%4'O")+P'$95')94E-49*)@4C'3"#'#847'$%4'.4**'*49*)#)@4'
2#)@4'5)-*#)+P'%4*".#*>'_,b=*'?9#4A%$#45'R$9$A4:49#'&6'G%4A9$9+7'$95'S8).53)%#8'V?RGLSX'A")54.)94*'%4+&::495'"*)9A'Bf'-%)9"%)$'$*'$':$%P4%'&6'*4@4%4'-%)9"%$C'$95'Jf'-%)9"%)$'$*'#84'#8%4*8&.5'6&%'
#84'*$:4'-%)9"%)$'#8%4*8&.5*>/]C/g
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208 chronic care integration for endemic non-communicable diseases
H84'+8&)+4'&6'$9#)87-4%#49*)@4*')*'.):)#45')9'-%4A9$9+7'37'#84'P9&<9'-1#)$.'6&%'3)%#8'5464+#*'<)#8'LSU')98)3)#&%*C'$95'.$+P'&6'*$64#7'5$#$'6&%':&*#'T%'$A49#*'4E+4-#'6&%':4#87.5&-$C'875%$.$^)94C'$95'9)645)-)94>';4+&::49545'$A49#*')9+."54'#8&*4'#8$#'8$@4'3449'*8&<9'#&'34'*$64'$95'4664+#)@4>'H84*4'$%4'.)*#45')9'&%54%'&6'-%464%49+4')9'TABLE 8.11>'LSU')98)3)#&%*'$%4'+&9#%$)95)+$#45')9'-%4A9$9+7>
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chapter!8 | hypertension 209
PROTOCOL 8.5'&"#.)94*'$9'$.A&%)#8:'6&%':$9$A4:49#'&6'87-4%#49*)&9'
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TABLE 8.8 Hypertensive Disorders of Pregnancy
Classification Definition Risks Role of antihypertensives
Chronic hypertension
BP 140/90 mmHgANDDiagnosis of hypertension prior to pregnancy or before 20 weeks of gestation
20% will develop preeclampsia22
Placental abruptionIntrauterine growth retardation
Does not reduce the risk of developing preeclampsiaMay reduce risk of maternal cerebral hemorrhage
Gestational hypertension
BP 140/90 mmHgANDDiagnoses or progression of hypertension after 20 weeks of gestationWITHOUTSignificant proteinuriaDefined as 2+ on a urine dipstick
50% will develop preeclampsia23
10% will develop severe preeclampsia
Does not reduce the risk of developing preeclampsiaMay reduce risk of maternal cerebral hemorrhage
Preeclampsia BP 140/90 mmHgANDDiagnosis or progression of hypertension after 20 weeks of gestationANDSignificant proteinuriaDefined as 2+ on a urine dipstick
25% will develop severe preeclampsiaEclampsia (seizures)Maternal stroke
Does not reduce the risk of developing severe preeclampsiaMay reduce risk of maternal cerebral hemorrhage
Severe preeclampsia
PreeclampsiaANDBP 160/110 mmHgOR
3+ proteinuriaORAny symptom of end-organ damage (oliguria, right-upper-quadrant pain, severe persistent headache, cerebral hemorrhage, nausea, pulmonary edema, low platelets [ 100,000], severe intrauterine growth restriction, or transaminitis [ twice normal])
Eclampsia (seizures)Maternal stroke
Does not reduce the risk of developing severe preeclampsiaMay reduce risk of maternal hemorrhage
YES
NO
YES
NO
YES
YES
NOYES
NO
YES
NO
YES
NO
BP ≥ 160/110mmHg
Check urine dipstick, evaluate for signs of preeclampsia or hypertensive emergency*
BP 140/90–160/110 mmHg
Recheck blood pressure at next
prenatal visit
≥ 2+ proteinuria
Initiate anti-hypertensive
treatment (Table 8.11)
Return to clinic in one week
Initiate antihypertensive treatment (Table 8.11)
Gestational age ≥ 20 weeks OR able to palpate
uterine fundus at umbillicus
Manage as chronic hypertension using medications preferred in
pregnancy (Table 8.11) ≥ 3+
proteinuria and/or danger
signs?
Seizures?Initiate MgSO4
(Table 8.9)Transfer to district hospital
for immediate delivery
Transfer to district hospital for prompt delivery
Danger signs?
Woman with positive pregnancy test and blood
pressure ≥ 140/90 mmHg x 2
* Symptoms of preeclampsia and/or hypertensive
emergency Dyspnea Headache Visual changes Right-upper-quadrant pain Nausea/vomiting
210 chronic care integration for endemic non-communicable diseases
PROTOCOL 8.5 Management of Hypertension in Pregnancy
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chapter!8 | hypertension 211
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8.8.2 Hypertension in Later Pregnacy (Gestational Hypertension and Preeclampsia)
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TABLE 8.9 Loading and Maintenance Dosing of Magnesium Sulfate in Eclampsia and Severe Preeclampsia (Adapted from IMPAC)17,18
Start with loading dose:Inject 4 grams (20 ml of 20% concentration) by IV over 20 minutes.ANDInject 5 grams (10 ml of 50% concentration) mixed with 1 ml of 1%–2% lidocaine IM in each buttock (for a total of 10 grams).If unable to establish IV, give only IM dose as loading dose.
If seizures recur after 15 minutes, give reloading dose:Inject 2 grams of 20% concentration IV over 5 minutes.
Follow with maintenance dose:Inject 5 grams of 50% concentration IM mixed with 1 ml of 1%–2% lidocaine in alternate buttocks every four hours.
Maximum total dose:40 g every 24 hours
Side-effect monitoring:Monitor for respiratory depression (respiratory rate 16), loss of reflexes and decreased urinary output ( 100 ml/4 hrs). Injecting the magnesium too quickly increases the risk of respiratory or cardiac depression.Stop the therapy if the respiratory rate falls below 16 per minute, patellar reflexes are absent, or urinary output is less than 100 mL over 4 hours.For respiratory depression, give calcium gluconate 1 g IV (10 ml of 10% solution) over 10 minutes
Other safety considerationsDo not leave the patient by herself.Place her on her left side.Transfer immediately to district hospital unless delivery is imminent
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212 chronic care integration for endemic non-communicable diseases
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8.8.5 Treatment of Preeclampsia According to Disease Classification
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TABLE 8.10 Recommended Medications for Management of Hypertension in Severe Preeclampsia
Medication Dosing Notes
Nifedipine (immediate release) 10 mg orally Fast acting
Methyldopa 250 mg orally Slower acting
8.8.5.1 Mild to Moderate Preeclampsia
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chapter!8 | hypertension 213
TABLE 8.11 Recommended Hypertension Medications and Dosing in Pregnancy
First-line drug Starting dose Increase dose by
Maximum dose
Notes
Methyldopa 250 mg 2x/day 250 mg 2x/day 500 mg 2x/day Best-proven safety in pregnancy, cheap, widely available
Second-line drug Starting dose Increase dose by
Maximum dose
Notes
Nifedipine (immediate release)
10 mg 3x/day 20 mg 3x/day 60 mg 3x/day
Amlodipine 5 mg 1x/day 5 mg 1x/day 10 mg 1x/day Can cause lower-extremity edema
Third-line drug Starting dose Increase dose by
Maximum dose
Notes
Atenolol 25 mg 1x/day 25 mg 1x/day 100 mg 1x/day Contraindicated if heart rate 55 bpm
Fourth-line drug Starting dose Increase dose by
Maximum dose
Notes
Hydralazine 25 mg 3x/day 25 mg 3x/day 50 mg 3x/day Headache common side e#ect.Expensive, requires thrice-daily dosing
214 chronic care integration for endemic non-communicable diseases
Chapter 8!References
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chapter!8 | hypertension 215
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chapter 9Rheumatic Heart Disease Prevention
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9.1 Prevention of Acute Rheumatic Fever: Management of Sore Throat
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218 chronic care integration for endemic non-communicable diseases
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PharyngitisGroup A
streptococcalpharyngitis
Rheumatic fever20% 2%
chapter!9 | rheumatic heart disease prevention 219
FIGURE 9.1 Progression from Pharyngitis to Rheumatic Fever
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220 chronic care integration for endemic non-communicable diseases
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TABLE 9.1 Clinical Decision Rules for Treatment of Pharyngitis
% with GAS not treated
% without GAS overtreated
Rule 1: WHO14
Pharyngeal exudate + tender and enlarged cervical lymph nodes88% 6%
Rule 2: Steinhoff12
Pharyngeal exudate OR enlarged cervical lymph nodes10% 60%
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_4'8$@4'54@4.&-45'$'%".4'3$*45'&9'5$#$'6%&:'#84'UA7-#)$9'4E-4%)49+4')9'*+8&&.2$A45'+8).5%49C'$95'$.*&'$'S$9$5)$9'+.)9)+$.'54+)*)&9'%".4'#4*#45')9'-&-".$#)&9*'34#<449'#84'$A4*'&6'B'$95']Z'VPROTOCOL 9.1X>
Assess for danger signs:1. Leaning forward and drooling2. Unable to swallow3. Stridor
Refer to district hospital immediately
≥ 2 of Following:1. Lymphandenopathy
2. Documented fever ≥ 383. Lack of cough
Runny nose?Cough?
Congestion?
Patient with a sore throat
YES
YES
NO
YES
Exudate?
Childbetween
5 and 15 yearsold?
Test for HIV if not recently testedor if has risk factors
YES
NO
NO
NO
YES
Runny nose?Cough?
Congestion?
Do not treat for streptococcus.Treat according to acute care
guidelines for respiratorycomplaints (see IMCI and
IMAI guidelines)
YES
NO
Treat as streptococcal pharyngitis(see Tables 9.2 and 9.3)
Treat as streptococcal pharyngitis
(see Tables 9.2 and 9.3)
chapter!9 | rheumatic heart disease prevention 221
PROTOCOL 9.1 Evaluation and Management of Pharyngitis
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222 chronic care integration for endemic non-communicable diseases
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TABLE 9.2 Antibiotic Regimens for Streptococcal Pharyngitis (Adults and Adolescents Dosing, Weight 27 kg)
Regimen Doses Cost Allergic Reactions16,17
Oral penicillin VK 500 mg, two times per day for 10 days
20 $0.66 Cutaneous 1%–2%
Intramuscular benzathine penicillin G
1.2 million units, single dose 1 $0.14 Cutaneous 1%–2%
Anaphylaxis 0.02%
Death 0.003%
Oral erythromycin (75 kg adult)
250 mg, four times per day 12 $6.38
TABLE 9.3 Antibiotic Regimens for Streptococcal Pharyngitis (Pediatric Dosing, Weight 27 kg)
Regimen Doses Cost
Oral penicillin VK 250 mg, two times per day for 10 days 20 $0.33
Intramuscular benzathine penicillin G 600,000 units, single dose 1 $0.09
Oral erythromycin (25-kg child) 12.5 mg/kg, three times per day 9 $0.27
9.2 Preventing Rheumatic Heart Disease: Management of Acute Rheumatic Fever and Secondary Prophylaxis for Rheumatic Fever
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chapter!9 | rheumatic heart disease prevention 223
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9.2.1 Acute Rheumatic Fever: Diagnosis and Follow-Up
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TABLE 9.4 Modified Jones Criteria for High-Risk Groups21,23,24
Major criteria (five) Minor criteria (four)
1. Carditis or subclinical (echocardiographic) carditis2. Polyarthritis or monoarthritis3. Chorea4. Erythema marginatum5. Subcutaneous nodules
Clinical1. Fever 38˚C2. Arthralgia
Laboratory3. Elevated acute phase reactants (erythrocyte
sedimentation rate 30 mm/h)4. PR-interval prolongation
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224 chronic care integration for endemic non-communicable diseases
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chapter!9 | rheumatic heart disease prevention 225
TABLE 9.5 Antibiotic Regimens for Secondary Prophylaxis of Rheumatic Fever
Adults ( 27 kg) Children ( 27 kg)
Oral penicillin VK 500 mg, two times per day 250 mg, two times per day
Intramuscular benzathine penicillin G 1.2 million units, once every 4 weeks
600,000 units, once every 4 weeks
Oral erythromycin (penicillin allergy) 250 mg, two times per day 10 mg/kg, twice per day
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9.3 Rheumatic Heart Disease Screening
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226 chronic care integration for endemic non-communicable diseases
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chapter!9 | rheumatic heart disease prevention 227
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TABLE 9.6 Echocardiographic Prevalence of Definite and Possible RHD in School-Aged Children
Country N Setting Population Definite or probable RHD
Possible RHD
Paar et al. 2010 41 Nicaragua 3150 Rural and urban
Community 0.6% 2.4%
Steer et al. 2009 37 Fiji 3462 Rural and urban
School-based 0.8% n/a
Carapetis et al. 2008 39 Tonga 5053 Rural and urban
School-based 3.3% 0.5%
Marijon et al. 2007 36 Cambodia 3677 Urban School-based 3.0% n/a
Marijon et al. 2007 36 Mozambique 2170 Urban School-based 2.1% n/a
Anabwani and Bonhoe#er 1996 42
Kenya 1115 Rural and urban
School-based 0.3% 7.3%
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228 chronic care integration for endemic non-communicable diseases
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TABLE 9.7 Echocardiographic Features of Left-Sided Heart Valves Thought Consistent with Rheumatic Heart Disease in High-Prevalence Settings by Three Sets of Criteria
World Health Organization 2001 24
Marijon et al. 2009 44
Preliminary World Health Organization/United States National Institutes of Health 2005 37
Properties of regurgitant jet
Holosystolic (mitral) or holodiastolic (aortic) regurgitation visible in at least two color planes with 1 cm extension and a velocity 2.5 m/s
Any degree in two planes
Definite Probable
2 cm, otherwise meeting World Health Organization 2001 criteria*
2 cm, otherwise meeting World Health Organization 2001 criteria*
Morphologic abnormalities
Not required Required** Required*** Not Required***†
Pathologic murmurs
Not required Not Required Required Required
* 1 cm of jet length is su$cient for aortic regurgitation.** Any two of the three that include leaflet tethering, leaflet thickening, or sub-valvular thickening.*** For mitral regurgitation, these include thickening of the valve or a hockey-stick/elbow deformity of the anterior leaflet; in
addition, for mitral stenosis, these also include tethering of the posterior leaflet, commissural thickening and calcification with a mean gradient 4 mmHg; for aortic regurgitation without obvious non-rheumatic causes, these include morphologic abnormalities of the mitral valve.
† Either significant left-sided valvular regurgitation, morphologic abnormalities, or mitral stenosis in the presence of patho-logic murmurs.
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Hig
h-ris
k gr
oup
(Chi
ldre
n ag
es 5
–15)
Follo
w-u
p pl
an fo
r oth
er
iden
tified
con
ditio
ns
NO
Refe
r to
dist
rict
NCD
clin
icYE
SD
efini
te
RHD
?
1. In
itiat
e ant
ibio
tic
prop
hyla
xis (
oral
or I
M)
2. A
ssig
n a
com
mun
ity
heal
th w
orke
r3.
Mon
thly
follo
w-u
p at
he
alth
cen
ter c
hron
ic
care
clin
ic.
YES
1. Co
unci
l reg
ardi
ng so
re
thro
at m
anag
emen
t2.
Par
ticip
ate
in ra
ndom
ized
tr
ial o
f ant
ibio
tics i
f ava
ilabl
e3.
Ass
ign
a co
mm
unity
he
alth
wor
ker
4. F
ollo
w-u
p ev
ery
6 m
onth
s at
dist
rict N
CD c
linic
.
NO
1. H
istor
y: a
ny re
colle
ctio
n of
seve
re jo
int p
ain,
sh
ortn
ess o
f bre
ath.
Con
sider
scre
enin
g qu
estio
ns fo
r epi
leps
y, m
uscu
losk
elet
al
disa
bilit
ies,
asth
ma
2. P
hysic
al e
xam
inat
ion:
hei
ght a
nd w
eigh
t, au
scul
tatio
n. C
onsid
er p
hysic
al e
xam
inat
ion
for o
ther
con
ditio
ns (e
.g., s
kin
infe
ctio
ns)
3. C
onsid
er sc
reen
ing
labo
rato
ry te
sts f
or
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ia, p
rote
inur
ia, H
IV4.
Scre
enin
g ec
hoca
rdio
grap
hy (r
estr
icte
d to
pa
rast
erna
l lon
g an
d ap
ical
4-c
ham
ber
view
s).
Mee
t ech
ocar
diog
raph
ic
Crite
ria fo
r defi
nite
or p
ossib
le
RHD
? (s
ee T
able
9.5
)
chapter!9 | rheumatic heart disease prevention 229
PROTOCOL 9.2 Screening for Rheumatic Heart Disease (and Other Conditions of School-Aged Children)
TABLE 9.8 Proposed Criteria for Definite and Possible RHD
Definite Possible
Properties of regurgitant jet At least mild-to-moderate regurgitation. Regurgitation visible in at least two color planes
Any degree in two planes
Morphologic abnormalities Required* Required*
Pathologic murmurs Not required Not Required
230 chronic care integration for endemic non-communicable diseases
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chapter!9 | rheumatic heart disease prevention 231
Chapter 9!References
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232 chronic care integration for endemic non-communicable diseases
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chapter!9 | rheumatic heart disease prevention 233
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chapter 10Chronic Respiratory Disease
10.1 The Burden of Chronic Respiratory Disease in Rural Rwanda
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10.1.1 The Impact of Biomass Fuels and Tuberculosis on Chronic Respiratory Disease
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236 chronic care integration for endemic non-communicable diseases
10.2 Integration of Chronic Respiratory Disease Management at Health-Center Level
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10.2.1 Initial Evaluation for Chronic Respiratory Disease at Health-Center Level
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YES
NO
NO
YES
YES
NO
YES
NO
YES
NO
YES
YES
NO
Initial evaluation:Chronic cough or
shortness of breath (≥ 3 weeks)
Respiratory rate ≥ 30/minAND wheezing OR
Patient acutely short of breath ORNot able to walk unaided OR
Fever ≥ 39
Fever, chills,productive
cough or HIV+
Serotest in pastyear?
Perform HIV test
Leg swelling, orthopnea, known
heart condition, murmur
Refer to district hospital NCD clinic for confirmation of suspected heart failure
Conjunctival pallor, post-
partum or other history of bleeding
Wheezing, night cough, worsened
by climate change or exercise
Refer to health center integrated chonic care clinic for probable
asthma or COPD (see Protocol 10.2)
1. Obtain CXR2. Obtain sputum smear x 3
Improvement?Cause of dyspnea
was likely pneumonia
1. Position (sit upright/leaning forward)2. If wheezing, give salbutamol 2 sprays every 15 min by
metered dose inhaler with spacer3. If known heart disease and uncomfortable lying down,
give furosemide (refer to acute decompensated heart failure protocol)
4. Refer urgently to district hospital
1. Treat with antibiotics (Adult dosing: doxycycline 100 mg 2x/day x 14 days or amoxicillin 500 mg 3x/day x 14 days)
2. If wheezing, salbutamol inhaler3. Have return in 1–2 weeks
1. Check hemoglobin if available2. Start elemental iron, Adults: 60 mg 2x/day,
Children ≤ 40 kg: 2–3 mg/kg 1x/day3. Albendazole 400 mg 2x/day x 7 days
chapter!10 | chronic respiratory disease 237
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PROTOCOL 10.1 Initial Management of Chronic Cough or Shortness of Breath at Health Center Acute Care Clinics
238 chronic care integration for endemic non-communicable diseases
10.2.2 Identification and Treatment of Emergency Conditions2
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TABLE 10.1 Evaluation of Asthma Attack Severity (Adapted from IUATLD Guidelines)19
Symptoms Mild asthma attack
Moderate asthma attack
Severe asthma attack
Imminent respiratory failure
Dyspnea With physical exertion
With speaking All the time All the time
Can speak in Full sentences Phrases Words Unable to speak
Mental status Normal Normal or agitated
Agitated Somnolent or confused
Respiratory rate Normal to fast Fast Very fast ( 30 breaths/min)
Very fast ( 30 breaths/min)
Pulse 100 100–120 120 Bradycardic
Peak expiratory flow (PEF) after salbutamol (% of patient’s best PEF or predicted PEF)
70% 50%–70% 50% or 100 liters/min
Cannot measure
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chapter!10 | chronic respiratory disease 239
TABLE 10.2 Causes of Chronic Dyspnea or Chronic Cough ( 3 Weeks)
System Disease Evaluate for
Respiratory Asthma Episodic wheezing
COPD Progressively worsening dyspnea
Bronchiectasis Large volume of purulent sputum
Acute bronchitis/pneumonia Fever, acute dyspnea, productive cough
Pulmonary tuberculosis Cough, hemoptysis, fevers, night sweats, weight loss
Cardiovascular Congestive heart failure Edema, orthopnea, rales
Pulmonary hypertension and right heart failure
Edema, ascites
Gastrointestinal Gastroesophageal reflux disease Symptoms of reflux, heartburn
Hematologic Anemia Conjunctival pallor, measure hemoglobin
Ear, nose, throat Allergic or non-allergic rhinitis Nasal congestion, itchy/watery eyes
Sinusitis (subacute/chronic) Postnasal drip, headache, rhinorrhea
Psychological Anxiety Dyspnea and chest tightness in social situations, palpitations, sweating, tingling in arms or fingers
Medication ACE inhibitors Usually non-productive cough shortly after starting the medication, though can occur at any time
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240 chronic care integration for endemic non-communicable diseases
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10.3 Diagnosis and Initial Management of Chronic Respiratory Disease in Health Center Integrated Chronic Care Clinics
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NO
NO
YES
YES
YES
NO
Complete history and physical exam, including peak flow measurement
1. Patient acutely short ofbreath and wheezing OR
2. RR ≥ 30 bpm
Assess asthmaseverity
(see Table 10.4)
Patient withsevere
asthma orCOPD
Patientwith typical
asthma symptoms,abnormal peak flow
or wheezing onexam?
Patient referred to health center
chronic care clinic (CCC) for suspected
asthma or COPD
1. Position (sit upright/leaning forward)2. Give salbutamol 2 sprays every 15 min by metered dose inhaler
using a spacer3. If has productive cough or fever, give dose of doxycycline 100 mg
or amoxicillin 500 mg (adult dosing)4. Give dose of prednisolone 2 mg/ kg (max 60 mg)5. Refer urgently to district hospital
1. Start appropriate asthma treatment (see Table 10.6 ) and give inhaler teaching2. Abendazole 400 mg 2x/day x 3 days if not treated within the last year3. Education about avoidance of triggers4. Follow-up in health center CCC 2 weeks5. Obtain CXR within next 6 months
1. Start appropriate asthma treatment (see Table 10.6) and give inhaler teaching
2. Albendazole 400 mg 2x/day x 7 days if not treated within the last year (adults)
3. Obtain sputum smear x 34. Refer to district hospital NCD clinic for CXR,
echocardiography and higher-level evaluation
1. Consider alternative diagnosis, including hyperventilation/somatization
2. May give trial of salbutamol3. Follow up in health center CCC
2 weeks –2 months for reassessment
chapter!10 | chronic respiratory disease 241
PROTOCOL 10.2 Initial Management of Asthma or COPD at Integrated Chronic Care Clinics
TABLE 10.3 Common Signs and Symptoms of Asthma
Symptoms are intermittent
Symptoms triggered by changes in weather, exposure to dust, exhaust, exercise or cooking smoke
Dyspnea
Wheezing
Cough NonproductiveNighttime
Chest tightness
Reduced PEF in setting of symptoms, 20% improvement with bronchodilators
242 chronic care integration for endemic non-communicable diseases
TABLE 10.4 Classification of Asthma Severity at Initial Visit26
Components of severity Intermittent Persistent
Mild Moderate Severe
Impairment Symptoms 2 days/week 2 days/week but not daily
Daily Throughout the day
Nighttime awakenings None 1–2x/month 3–4x/month 1x/week
Salbutamol use for symptom control
2 days/week 2 days/week but not daily
Daily Several times per day
Interference with normal activity
None Minor limitation
Some limitation
Extremely limited
Risk Exacerbations requiring oral systemic cortico-steroids (prednisolone)
0–1/year 2 exacerbations in 6 months requiring oral systemic corticosteroids, or 4 wheezing episodes/year lasting 1 day AND risk factors for persistent asthma
Consider severity and interval since last exacerbation. Frequency and severity may fluctuate over time. Exacerbations of any severity may occur in patients in any severity category.
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chapter!10 | chronic respiratory disease 243
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+&95)#)&9*')9'&"%'*4##)9A>'_)#8'#84'4E+4-#)&9'&6'.&9A2$+#)9A'34#$'$A&9)*#*'
TABLE 10.5 Asthma Control Test25
Maximum score is 25 (points are 1–5 in order as below) 19 means asthma may not be well controlled
In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at work, school, or home?
1 All of the time
2 Most of the time
3 Some of the time
4 A little of the time
5 None of the time
During the past 4 weeks, how often have you had shortness of breath?
1 More than once a day
2 Once a day
3 3–6 times a week
4 Once or twice a week
5 Not at all
During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) wake you up at night or earlier than usual in the morning?
1 4 or more nights a week
2 2 or 3 nights a week
3 Once a week
4 Once or twice
5 Not at all
During the past 4 weeks, how often have you used your rescue inhaler (salbutamol)?
1 3 or more times per day
2 1 or 2 times per day
3 2 or 3 times per week
4 Once a week or less
5 Not at all
How would you rate your asthma control during the past 4 weeks?
1 Not controlled at all
2 Poorly controlled
3 Somewhat controlled
4 Well controlled
5 Completely controlled
244 chronic care integration for endemic non-communicable diseases
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54-495*'&9'#84'*4@4%)#7'&6'#84'-$#)49#=*'*7:-#&:*'V*44'TABLE 10.7X>
chapter!10 | chronic respiratory disease 245
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246 chronic care integration for endemic non-communicable diseases
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TABLE 10.6 Asthma Step Therapy
STEP
-UP
w
hen
poor
con
trol
STEP
-DO
WN
w
hen
doin
g w
ell
Asthma severity Salbutamol Beclomethasone Aminophylline Prednisone
Step 5: Severe uncontrolled Yes High dose Yes Yes
Step 4: Severe persistent Yes High dose Yes No
Step 3: Moderate persistent Yes Medium dose No No
Step 2: Mild persistent Yes Low dose No No
Step 1: Intermittent Yes No No No
chapter!10 | chronic respiratory disease 247
10.4 Follow-Up Management of Asthma
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TABLE 10.7 Asthma Medication Dosing
Salbutamol100 mcg (inhaler)
Beclomethasone50 and 250 mcg (inhaler)Always use a spacer
Aminophylline100 mg tab
Prednisone5 mg tab
Adults and children
30 kg
1–2 pu#s, 3x/dayas needed
High:1500 mcg (3 pu#s 2x/d)
300 mgin 3 divided doses
1–2 mg/kg/d in two divided doses (max 60 mg) x 7–10 daysNote:If new CRD diagnosis, first, rule out TB (smear x 3, CXR)
Medium:1000 mcg(2 pu#s 2x/d)
Low:500 mcg (1 pu# 2x/d)
Children 10–30 kg (always use spacers)
1–2 pu#s, 3x/day as needed
High:1000 mcg/d(2 pu#s 2x/d)
n/a 2 mg/kg once per day x 5 days (max 60 mg)
Medium:500 mcg/d (1 pu# 2x/d)
Low:250 mcg/d(1 pu# 1x/d)
Children 10 kg
REFER TO PHYSICIANVery small children should use a metered-dose inhaler with a spacer, or a nebulizer if available.
NO
NO
NO
YES
YES
YES
Patie
nt w
ithdi
agno
sis o
fas
thm
a or
COPD
1. Pa
tient
acu
tely
shor
t of
brea
th a
nd w
heez
ing
OR
2. R
R ≥
30
bpm
Ass
ess d
egre
e of
asth
ma
cont
rol,
com
pare
to la
st v
isit
(see
Tab
le 10
.5)
Step
up
trea
tmen
t(s
ee T
able
10.6
) and
follo
w u
p in
2 w
eeks
1. Co
ntin
ue m
axim
um th
erap
y2.
Ref
er to
dist
rict h
ospi
tal N
CD c
linic
Sym
ptom
impr
ovem
ent?
On
max
imum
ther
apy?
Cont
inue
cur
rent
ther
apy,
retu
rn in
3 m
onth
s
Step
dow
n or
cont
inue
cur
rent
ther
apy
(see
Tab
le 10
.6)
Ther
apy
x 3
mon
ths
1. Po
sitio
n (s
it up
right
/lea
ning
forw
ard)
2. G
ive
salb
utam
ol 2
spra
ys e
very
15 m
in b
y m
eter
ed d
ose
inha
ler w
ith a
spac
er3.
If h
as p
rodu
ctiv
e co
ugh
or fe
ver,
give
dos
e of
dox
ycyc
line
100
mg
or a
mox
icill
in 5
00 m
g (a
dult
dosin
g)4.
Giv
e do
se o
f pre
dniso
lone
2 m
g/kg
(max
60
mg)
5.
Ref
er u
rgen
tly to
hos
pita
l
248 chronic care integration for endemic non-communicable diseases
PROTOCOL 10.3 Follow-Up Management of Asthma or COPD at Health-Center Level
chapter!10 | chronic respiratory disease 249
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250 chronic care integration for endemic non-communicable diseases
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chapter!10 | chronic respiratory disease 251
Chapter 10!References
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chapter!10 | chronic respiratory disease 253
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256 chronic care integration for endemic non-communicable diseases
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appendix aEssential Equipment and Medicines1,2
A.1 Essential EquipmentEssential equipment Health
centerDistrict hospital
Referral center
Automatic sphygmomanometer (blood pressure machine) with pediatric, small adult, and adult cu#s, and AC adapter
x x x
Glucometer with test strips and lancets x x x
Lab: Chemistry testing (point-of-care) x x
Lab: HbA1c testing (point-of-care) x x
Lab: Hemoglobin testing x x x
Lab: HIV testing x x x
Lab: PT/INR testing (point-of-care) x x
Lab: Urinalysis x x x
Monofilament x x x
Multifunction ultrasound machine (with abdominal, cardiac, and obstetric probes) with ultrasound gel
x x
Nebulizer x x
Peak flow meter x x x
Scale x x x
Tape measure/ruler x x x
Water bottle spacers (for inhaler) x x x
A.2 Essential Medicinesx = Currently recommended by Rwanda MOHt = Recommended for chronic care integration
Pregnancy categories
Category A Controlled studies show no risk, ok to use
Category B No evidence of risk in humans, ok to use
Category C Risk cannot be ruled out, use only if there is no alternative.Potential benefit may outweigh potential risk
Category D Positive evidence of risk, avoid use
Category X Contraindicated in pregnancy, do not use
258 chronic care integration for endemic non-communicable diseases
Palliative care Pregnancy category
Health center
District hospital
Referral center
Analgesia
Acetaminophen/paracetamol B x x x
Amitriptyline C x x
Diazepam D x x x
Diclofenac C x x x
Ibuprofen B x x x
Morphine, liquid preparation C t x x
Phenytoin (Dilantin) D x x
Prednisolone C x x x
Anti-emetics
Chlorpheniramine B x x x
Dexamethasone C x x x
Haloperidol C x x
Metoclopramide B x x x
Promethazine C x x x
Constipation
Bisacodyl C x x x
Glycerine suppository C x x x
Lactulose syrup B x x x
Naloxone B t x x
Diarrhea
Hyoscine butylbromide C x x x
Pruritus
Betamethasone cream C x x x
Permethrin B t x x
Other
Fluoxetine C t x x
appendix a | essential equipment and medicines 259
Heart failure, cardiac surgery, hypertension, anticoagulation, and chronic kidney disease
Pregnancy category
Health center
District hospital
Referral center
Amlodipine C t x x
Aspirin C–D x x x
Atenolol D t x x
Captopril D t x x
Carvedilol C t t tErythromycin B x x x
Furosemide (Lasix) C t x x
Hydralazine C t x x
Isosorbide dinitrate C t t x
Lisinopril D t t tMagnesium sulfate A x x x
Methyldopa A t t x
Nifedipine retard C t t x
Penicillin G benzathine B x x x
Penicillin V B x x x
Propranolol C t t x
Spironolactone (Aldactone) D t t x
Warfarin X t t
DiabetesPregnancy category
Health center
District hospital
Referral center
Amitriptyline C t x x
Glibenclamide (Daonil) C x x x
Insulin Lente (NPH) B x x x
Insulin Rapide (Regular) B x x x
Insulin Mixte (70/30) B x x x
Metformin B x x x
260 chronic care integration for endemic non-communicable diseases
Chronic respiratory diseasePregnancy category
Health center
District hospital
Referral center
Aminophylline C x x x
Beclomethasone inhaler C * * x
Chlorpheniramine B x x x
Doxycycline D x x x
Prednisolone C x x x
Salbutamol inhaler C x x x
EpilepsyPregnancy category
Health center
District hospital
Referral center
Carbamazepine (Tegretol) D x x x
Phenobarbital D x x x
Phenytoin (Dilantin) D * x
Valproic acid (Depakote) D x x
Appendix A!References
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J' F$+7'S[C'L%:*#%&9A'FFC'T&.:$9'RGC'F$9+4'F;C'45*>'F4E)2S&:-=*'(%"A'?96&%:$#)&9',$953&&P'J1/12J1//W'L'S&:-%4849*)@4';4*&"%+4'6&%'L..'S.)9)+)$9*'$95',4$.#8+$%4'G%&64**)&9$.*>'/d#8'U5)#)&9>'J1/12J1//>',"5*&9C'b8)&W'F4E)2S&:-h'J1/1>
appendix bCost Models
H84'-%)+4*'6&%':45)+$#)&9*'.)*#45'84%4'$%4'#84'.&<4*#'&3#$)945'37'G$%#94%*'?9',4$.#8')9';<$95$'6&%'A494%)+*'#8%&"A8'*4@4%$.'5)664%49#'*"--.)4%*>'H84*4'$%4'$+#"$.'-%)+4*'-$)5>'F&<4%'-%)+4*':$7'34'$+8)4@$3.4'#8%&"A8'.$%A4%2*+$.4'-"%+8$*4*'$95'#8%&"A8'5)%4+#'94A&#)$#)&9'<)#8':$9"6$+#"%4%*>
B.1 Summary of Operational Cost Models
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2$3.4'#8%&"A8'54+49#%$.)^$#)&9'&6'+8%&9)+'+$%4'*4%@)+4*'6&%'`S(*'5&<9'#&'#84'5)*#%)+#28&*-)#$.'.4@4.')9'$..'5)*#%)+#*>'H84':&54.'$.*&'*8&<*'#84':$%A)9$.'&-4%$#)&9$.'+&*#*'&6'$'9$#)&9$.'+$%5)$+'*"%A)+$.'-%&A%$:'-4%26&%:)9A'B11'*"%A4%)4*'-4%'74$%>
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L*'+8%&9)+'+$%4'*4%@)+4*'$%4'54+49#%$.)^45'#&'#84'84$.#82+49#4%'[email protected]'
+&*#*>'L#'#84'*$:4'#):4C'#84'+&"9#%7=*')9#4%9$.'*&"%+4*'&6'%4@49"4'<)..'+&9#)9"4'#&')9+%4$*4'$*'<4..>
262 chronic care integration for endemic non-communicable diseases
B.2 CardiomyopathyB.2.1 Cost Inputs
Individual medication costs Price per tablet Goal regimen Annual cost
Furosemide 40 mg tablets $0.0029 40 mg 2x/d $2.08
Lisinopril 10 mg tablets $0.01 20 mg 1x/d $7.37
Carvedilol 25 mg tablets $0.035 25 mg 2x/d $25.6
Isosorbide dinitrate (IDN) 20 mg tablets
$0.025 20 mg 3x/d $27.2
Hydralazine 50 mg tablets $0.023 25 mg 3x/d $23.9
Spironolactone $0.020 25 mg 1x/d $7.3
B.2.2 Annual Regimen Costs Per PatientRegimen Annual cost
FLC: Furosemide 40 mg 2x/d, lisinopril 20 mg 1x/d, carvedilol 25 mg 2x/d
$40.25
FHIC: Furosemide 40 mg 2x/d, hydralazine 50 mg 3x/d, IDN 20 mg 3x/d, carvedilol 25 mg 2x/d
$90.46
t Prevalence given for the entire population.tt 300 cases per year.
Average annual cost
ConditionCase- finding rate
Population prevalence. Cases found Total Per patient Per capita
Cardiomyopathy 30% 0.2% 6,000 $2,009,506 $334 $0.20
Cardiac surgical follow-up
3% 0.1% 300 $3,709 $412 $0.012
Screening and follow-up for HIV nephropathy
100% 0.1% 9,000 $46,873 $5 $0.005
Diabetes 50% 0.44% 22,000 $3,806,655 $173 $0.38
Hypertension (160/90 threshold)
100% 4% 400,000 $7,632,542 $9 $0.76
Chronic respiratory disease
15% 2% 24,900 $1,453,695 $57 $0.14
Epilepsy 30% 1% 30,000 $738,003 $25 $0.07
Chronic care integration subtotal
$4,393,920 $1.57
Cardiac surgery (initial surgery)tt
3% 0.1% 300 $1,164,000 $3,880 $0.12
TOTAL $4,393,920 $1.69
appendix b | cost models 263
Other program costs (per patient) Annual cost
Laboratory testing (point-of-care chemistries @ $9.8 during 5 visits) $59
Transport (12 visits per year @ $3 per visit) $48
Community health workers (@ $30 per month divided over 5 patients) $72
NCD nurse (@ $10,000 base; 12 visits) $33
Marginal cost of hospitalization (5 days per year at $15 per day) $75
Subtotal $287
B.2.3 Population Age Distribution and Case-Finding (Catchment Area: 350,000)
Estimated cardiomyopathy prevalence 0.2%
Case-finding 30%
Total cardiomyopathy population 700
Total cardiomyopathy patients enrolled in program 210
B.2.4 Total Marginal Costs Per CapitaAnnual cost
Medication costs per patient (85% on FLC and 15% on FHIC) $47.8
Other program costs per patient $287
Total costs per patient $334
Marginal annual program cost $70,333
Marginal annual cost per capita $0.20
B.3 Cardiac SurgeryB.3.1 Cost InputsB.3.1.1 Follow-Up Cost Inputs
Medication Price per unit/tablet Goal regimen Annual cost
Warfarin 5 mg tablets $0.13 5 mg 1x/d $46
Warfarin 1 mg tablets $0.06 1 mg 1x/d $21
INR cartridge $3 16 test/yr $48
$0
$2,815
$5,630
$8,444
$11,259
50 100 150 200 250 300
Number of Surgeries per Year
average fixed cost/patient average variable cost/patient
264 chronic care integration for endemic non-communicable diseases
B.3.1.2 Surgical Cost Inputs (At 300 Cases Per Year)Item Unit cost Number Total annual cost
Operating supplies $800 300 $240,000
ICU costs $500 300 $150,000
Hospitalization costs $600 300 $180,000
Mechanical valves (2 out of 3 cases) $1000 200 $200,000
Facility cost fixed fixed $50,000
Equipment depreciation annual fixed fixed $20,000
Surgeon salary $72,000 2 $144,000
Perfusionist salary $12,000 2 $24,000
Scrub nurse salary $9,000 2 $18,000
Circulating nurse salary $9,000 2 $18,000
Anesthesiologist salary $40,000 2 $80,000
ICU nurse salary $10,000 4 $40,000
Total surgical cost $1,164,000
Total surgical per patient cost $3,880
B.3.1.3 Average Cardiac Surgical Costs as a Function of the Number of Annual Operations
$*'#84'9":34%'&6'&-4%$#)&9*'-4%'74$%')9+%4$*4*>
appendix b | cost models 265
B.3.1.4 Regimen and Follow-Up Costs
Visits per year Cost per visitAnnual cost per patient
INR cartridge 16 3 $48
Transport 16 3 $48
Echocardiography 2 72 $144
Community health worker N/A N/A $72
Warfarin 5 mg 1x/d N/A N/A $67
NCD nurse (@ $10,000 base), 12 visits
12 $2.78 $33.3
Subtotal $412
B.3.2 Population Age Distribution and Case-FindingPopulation of Rwanda 10,000,000
Estimated population prevalence of advanced RHD 0.1%
Total advanced RHD population in need of surgery 10,000
B.3.3 Total Marginal Costs Per Capita (At 300 Cases Per Year)Total surgical cost per patient cost $3,880
Total follow-up cost per patient per year $412.1
Marginal annual follow-up cost $160,439
Annual per capita cost $0.13
B.4 Screening for HIV NephropathyB.4.1 Cost Inputs
Medication or lab Price per unit Goal regimen Annual cost
Lisinopril 10 mg tablets $0.01 5 mg 1x/d $1.84
Urine dipstick $0.02 N/A N/A
Creatinine $3 N/A N/A
B.4.2 Marginal Follow-Up CostsOther program costs (per patient enrolled) Annual cost
Laboratory testing (point-of-care chemistries @ $9.8 x 6 visits) $58.8
266 chronic care integration for endemic non-communicable diseases
B.5 DiabetesB.5.1 Cost Inputs
MedicationPrice per unit/tablet Goal regimen
Units/tablets per day Annual cost
Insulin 70/30 (mixte)100 IU/mL, 10 mL
$0.009 15 U 2x/d 30 $99
Insulin regular (rapide)100 IU/mL, 10 mL
$0.010 10 U 2x/d 20 $72
Insulin NPH (lente)100 IU/mL, 10 mL
$0.010 15 U 2x/d 30 $109
Syringes(1 mL, 26 g needle)
$0.088 2x/d 2 $65
Metformin500 mg tablets
$0.010 1000 mg 2x/d 4 $15
Glibenclamide5 mg tablets
$0.003 5 mg 2x/d 2 $2
Lisinopril10 mg tablets
$0.01 5 mg 1x/d 0.5 $2
Total costs
Screening laboratory cost $1,057.88
Medication cost $580.62
Follow-up costs $58.8
Total annual program cost $1,697.30
Marginal per capita program cost $0.005
B.4.3 Population Age Distribution and Case-FindingTotal population size 350,000
HIV population prevalence (all ages) 2%
HIV proteinuria prevalence 6%
Total HIV+ population 5,250
Total with HIV and proteinuria 315
B.4.4 Total Marginal Costs Per CapitaCost to screen population Cost
Urine dipstick for screening population $112.88
Creatinine for patients with proteinuria $945
Total $1,057.9
appendix b | cost models 267
Cost estimates Medications Clinic visits. Lab testing† FSBG‡ CHW salary Total annual cost
Oral $19 $18 $27 N/A N/A $64
Mixte insulin $165 $36 $30 $20 $87 $338
Lente insulin $176 $36 $30 $20 $87 $349
Lente + Regular insulin
$207 $36 $30 $20 $87 $380
Testing supply Units per package Package price Price per test
Finger-stick blood glucose N/A N/A $0.35
Creatinine N/A N/A $3
Urine dipstick 100 $2.2 $0.02
Point-of-care HbA1c 20 $177.2 $8.86
B.5.2 Annual Regimen Costs Per PatientRegimen Components
Oral Metformin 1000 mg 2x/d, Glibenclamide 5 mg 1x/d, Lisinopril 5 mg 1x/d
Mixte Mixte 70/30 15 Units 2x/d, Lisinopril 5 mg 1x/d
Lente Lente 15 Units 2x/d, Lisinopril 5 Units 1x/d
Lente + Regular Lente 10 Units 1x/d + Regular 10 Units 2x/d, Lisinopril 5 mg 1x/d
t Clinic cost: $3/visit. If on oral therapy: 6 visits/year. If on insulin: 12 visits/year.† Annual testing: finger-stick glucose at each visit; creatinine 2x/year, HbA1c 2x/year.‡ If on insulin, 56 finger-stick blood glucose (FSBG) in the community per year (2 FSBG per day x 7 days, done 4 times per year).
B.5.3 Population Age Distribution and Case-FindingTotal population of catchment area 350,000
Percent of population over age 20 years (adults) 44%
Prevalence of diabetes in adults 1%
Case-finding rate 50%
Adults in catchment area 154,000
Adults with diabetes 1540
Cases found 770
268 chronic care integration for endemic non-communicable diseases
t H = HCTZ; N = amlodipine; L = lisinopril; A = atenolol
B.6 Hypertension Cost ModelsB.6.1 Cost Inputs
Medication Price per tablet Goal regimen Annual cost
HCTZ 25 mg tablets $0.003 25 mg 1x/d $1.03
Amlodipine 5 mg tablets $0.01 10 mg 1x/d $4.69
Lisinopril 10 mg tablets $0.01 20 mg 1x/d $7.37
Atenolol 50 mg tablets $0.01 25 mg 1x/d $0.97
Methyldopa 250 mg tablets $0.02 500 mg 2x/d $33.6
Hydralazine 25 mg tablets $0.04 50 mg 3x/d $83.9
Labetalol 100 mg tablets $0.17 200 mg 2x/d $250.6
Nifedipine 10 mg tablets $0.01 20 mg 2x/d $19
Nifedipine retard 20 mg tablets $0.02 20 mg 2x/d $4.6
B.6.2 Annual Regimen Costs Per Patient.
Medication regimens Annual cost per patient
1. H: HCTZ 12.5 mg $0.59
2. HN: HCTZ 25 mg, amlodipine 10 mg $6.57
3. HNL: HCTZ 25 mg, amlodipine 10 mg, lisinopril 20 mg $16.04
4. HNLA: HCTZ 25 mg, amlodipine 10 mg, lisinopril 20 mg, atenolol 25 mg
$19.56
B.5.4 Total Marginal Costs Per CapitaTotal cost
RegimenProportion of patients on this regimen
Estimated patient load
Total annual cost
Oral 66% 505 $32,406
Lente insulin 13% 98 $34,315
Lente + Regular insulin 22% 167 $63,394
Total 770 $130,114
Annual Marginal Cost $0.37
appendix b | cost models 269
B.6.3 Population Age Distribution and Case-FindingTotal population of catchment area (district) 100% 350,000
Percent of population over age 30 years (adults) 30% 105,000
Prevalence of stage I (>140/90) 7% 24,500
Prevalence of stage II (>160/100) 3% 10,500
Prevalence of stage III (>180/110) 1% 3,500
B.6.4 Total Marginal Costs Per Capita
Program costs by treatment threshold140/90
threshold160/100 threshold
180/110 threshold
Population at risk (# patients) 38,500 14,000 3,500
Total annual medication costs $143,356 $128,856 $59,837
Total annual clinic costs $199,500 $126,000 $63,000
Total laboratory costs $11,014 $6,812 $3,437
Total supply costst $5,471 $5,471 $5,471
Total costs $359,341 $267,139 $131,744
Average annual medication cost per patient
$3.72 $9.20 $17.10
Annual per capita medication cost $0.41 $0.37 $0.17
Marginal annual per capita total cost $1.03 $0.76 $0.38
t Automatic blood pressure machines (1 per 200 population @ $46.89 each).
t H = HCTZ; N = amlodipine; L = lisinopril; A = atenololtt Clinic cost: Stage I (1 visit per year); Stage II (2 visits per year); Stage III (6 visits per year). $3/visit
Hypertension stage Regimen.
Total clinic costs.. Medication
Laboratory testing Total costs
Stage I (140/90)
100% H $3 $0.59 $0.17 $3.7
Stage II ( 160/100)
100% HN $6 $6.57 $0.32 $12.9
Stage III ( 180/110)
70% HNL, 30% HNLA
$18 $17.10 $0.98 $36.1
Hypertension stage Projected yearly lab monitoringLaboratory costs per patient per year
Stage I (140/90) Urine dipstick 1x/y, creatinine 1x/y for 5%
$0.17
Stage II ( 160/100) Urine dipstick 1x/y, creatinine 1x/y for 10%
$0.32
Stage III ( 180/110) Urine dipstick 1x/y, creatinine 1x/y for 20%, chemistries 5%
$0.98
270 chronic care integration for endemic non-communicable diseases
B.7.3 Population Age Distribution and Case-FindingTotal population of catchment area 350,000
Prevalence of chronic respiratory disease 2%
Case-finding rate 15%
Total cases of chronic respiratory disease (in those over 5 years of age) 24,500
Cases found 871
t Including transportation cost.tt Includes community health worker e#ort for directly observed therapy.
Asthma severity MedicationsClinic visits
Cost per clinic visit
Total clinic visit cost
Total cost per patient
Intermittent $20 3 $3 $9 $29
Moderate persistent $53 10 $3 $30 $83
Severe persistent $79 12 $7* $83 $211tt
Severity classificationEstimated severity distribution Patients Total annual cost
Intermittent asthma 60% 523 $15,318
Moderate persistent 35% 305 $25,361
Severe persistent 5% 44 $9,213
Total 100% 490 $49,892
B.7 Chronic Respiratory Disease Cost ModelsB.7.1 Cost Inputs
Individual medication costsPrice per unit/tablet Goal regimen
Annual cost
Salbutamol 0.1 mg inhaler $0.01 200 mcg 4x/d $20
Beclomethasone 250 mcg inhaler, medium dose
$0.02 500 mcg 2x/d $33
Beclomethasone 250 mcg inhaler, high dose $0.02 750 mcg 2x/d $49
Aminophylline 100 mg tablets $0.00 200 mg 3x/d $10
B.7.2 Annual Regimen Costs Per PatientAsthma severity Regimen
Intermittent Salbutamol 200 mcg 4x/d
Moderate persistent Salbutamol 200 mcg 4x/d, beclomethasone 500 mcg 2x/d
Severe persistent Salbutamol 200 mcg 4x/d, beclomethasone 750 mcg 2x/d, aminophylline 200 mg 3x/d
appendix b | cost models 271
B.8 Epilepsy Cost ModelsB.8.1 Cost Inputs
MedicationPrice per tablet/unit Goal regimen
Annual cost per patient
Carbamazepine 200 mg tablets $0.02 200 mg 2x/d $11.1
Phenytoin 100 mg tablets $0.01 150 mg 2x/d $6.1
Phenobarbital 100 mg tablets $0.01 100 mg 1x/d $2.11
Valproic acid 150 mg tablets $0.11 150 mg 3x/d $116.1
Valproic acid 500 mg tablets $0.34 500 mg 3x/d $370.9
B.7.4 Total Marginal Costs Per Capita
Severity classificationTotal annual medication cost
Total annual clinic costs Total CHW cost Total annual cost
Intermittent asthma $10,612 $4,706 - $15,318
Moderate persistent $16,210 $9,151 - $25,361
Severe persistent $3,461 $2,615 $3,137 $9,213
Total $30,283 $16,471 $3,137 $49,892
Annual cost per patient $35 $19 $4 $57
Marginal annual per capita cost $0.09 $0.05 $0.01 $0.14
B.8.2 Annual Regimen Costs Per Patient
RegimenAnnual regimen costs (per patient)
Annual clinic visits
Cost per clinic visit
Annual clinic visit cost
Total annual cost
Phenobarbital 100 mg 1x/d
$2.12 6 $3 $18 $20
Carbamazepine 100 mg 2x/d
$11.08 6 $3 $18 $29
B.8.3 Population Distribution and Case-FindingCatchment area 350,000
Epilepsy prevalence (generalized seizures) 0.5%
Epilepsy prevalence (partial seizures) 0.5%
Case-finding rate 30%
Total population with generalized seizures 1750
Total population with partial seizures 1750
Total cases found 1050
272 chronic care integration for endemic non-communicable diseases
B.8.4 Total Marginal Costs Per CapitaEstimated total marginal program cost $25,830
Estimated marginal per capita program cost $0.07
appendix cIndicators for Monitoring and Evaluation
C.1 Heart Failure and Post-Cardiac Surgery Follow-Up
Demographics
Percent male and female
Median age
Number of new patients enrolled during reporting period
Total number of patients at the end of reporting period
Total number of patients at the end of reporting period by district and sector
Diagnosis and Case-Finding
Number and percent of patients without a cardiology consultation since enrollment
Number and percent of patients without a preliminary echocardiogram, preliminary diagnosis or both
Number and percent of patients referred each quarter to NCD heart failure clinic and confirmed not to have heart failure
Percent of patients without a creatinine check in the last 6 months
Percent in each diagnostic category (cardiomyopathy, pure mitral stenosis, other rheumatic heart disease, pericardial disease, congenital heart disease)
Number/percent with creatinine 200 !mol/L
Number of post-cardiac surgery patients
Interventions
In the cardiomyopathy subgroup, percent with heart rate 60 bpm at last visit not on carvedilol
In the cardiomyopathy subgroup, percent on lisinopril or captopril
In the mitral stenosis subgroup, percent with heart rate 60 bpm at last visit not on atenolol
In the rheumatic heart disease subgroup, percent on penicillin
In the subgroup of women < 50 years old, percent using modern contraception
Case-Holding/Retention
Percent and number of patients not seen in the last 6 months
Percent and number of patients not seen in the last 3 months
Percent and number of patients without a community health worker
Palliative Care
Percent and number of patients with reported pain score 0 or 1
Percent and number of patients with reported dyspnea score 0 or 1
274 chronic care integration for endemic non-communicable diseases
Palliative Care (continued)
Percent and number of patients with improvement of pain score since the last reporting period
Percent and number of patients with improvement of dyspnea score since the last reporting period
Percent and number of patients prescribed morphine for symptom relief
Outcomes
Number and percent of patients enrolled in the heart failure program who died in the last reporting period
Of patients enrolled in the heart failure program, number of hospitalizations in the last reporting period
Of the patients with a mechanical replacement valve, the number and proportion whose INR has been between 2 and 4 the entire time since the last reporting period
Data Quality
Percent and number of patients without an intake form
appendix c | indicators for monitoring and evaluation 275
C.2 Cardiac Surgical Referral and Case Selection
Demographics
Percent male and female
Median age
Number of new patients enrolled during reporting period
Total number of patients at the end of reporting period
Total number of patients at the end of reporting period by district and sector
Diagnosis and Case-Finding
Total number of cases referred for cardiac surgery evaluation since the last reporting period
Of the cases referred, the number and percent confirmed to be surgical candidates
Of the cases confirmed to be surgical candidates, the number and percent who have single valve disease
Of the cases confirmed to be surgical candidates, the number and percent who have disease of 2 or more valves
Of the cases confirmed to be surgical candidates, the number and percent who are labeled as requiring surgery within 1 year
Interventions
Of the number of cases referred for cardiac surgery, the number and percent who receive valve replacement
Of the number of cases referred for cardiac surgery, the number and percent who receive valve repair
Case-Holding/Retention
Of the patients on the cardiac surgery registry, the number and percent who have not seen a cardiologist in the last 12 months
Of the patients on the cardiac surgery registry, the number and percent who have not had a cardiologist echocardiogram in the last 12 months
Palliative Care
Percent and number of patients with reported pain score 0 or 1
Percent and number of patients with reported dyspnea score 0 or 1
Percent and number of patients with improvement of pain score since the last reporting period
Percent and number of patients with improvement of dyspnea score since the last reporting period
Percent and number of patients prescribed morphine for symptom relief
Outcomes
Number and percent of patients enrolled in the cardiac surgery program who died during the last reporting period
Data Quality
Percent and number of patients without a contact phone number
276 chronic care integration for endemic non-communicable diseases
C.3 Renal Failure
Demographics
Percent male and female
Median age
Number of new patients enrolled during reporting period
Total number of patients at the end of reporting period
Total number of patients at the end of reporting period by district and sector
Diagnosis and Case-Finding
Percent and number of patients with documented proteinuria that have ever had a creatinine check
Percent and number of patients referred from HIV clinic that have HIV and proteinuria
Of those enrolled in the renal failure program, percent and number of patients with stage IV or V CKD (eGFR 15 ml/min)
Interventions
Percent and number of patients with proteinuria who are treated with lisinopril or captopril
Case-Holding/Retention
Percent and number of patients not seen in the last 6 months
Percent and number of patients not seen in the last 3 months
Percent and number of patients without a community health worker
Palliative Care
Percent and number of patients with reported pain score 0 or 1
Percent and number of patients with reported dyspnea score 0 or 1
Percent and number of patients with improvement of pain score since the last reporting period
Percent and number of patients with improvement of dyspnea score since the last reporting period
Percent and number of patients prescribed morphine for symptom relief
Outcomes
Percent and number of patients with hyperkalemia (K 5.0 mEq/dL)
Percent and number of patients with renal failure who have blood pressure controlled ( 130/80 mmHg)
Data Quality
Percent and number of patients without an intake form
appendix c | indicators for monitoring and evaluation 277
C.4 Diabetes
Demographics
Percent male and female
Median age
Number of new patients enrolled during reporting period
Total number of patients at the end of reporting period
Total number of patients at the end of reporting period by district and sector
Diagnosis and Case-Finding
Percent and number of patients referred each quarter to NCD diabetes clinic and confirmed not to have diabetes
Percent and number of patients referred to NCD diabetes clinic and confirmed to have diabetes based on (a) fasting glucose 126 mg/dL, (b) HbA1c 6.5%
Percent without an HbA1c in the past 6 months
Percent without a documented foot examination in the past 12 months
Percent with a documented eye examination in the past 2 years
Interventions
Percent on any insulin
Percent on NPH + regular insulin
Percent on NPH insulin alone
Percent on Mixte insulin
Percent on metformin
Percent on glibenclamide
Case-Holding/Retention
Percent and number of patients not seen in the last 6 months
Percent and number of patients not seen in the last 3 months
In subgroup (on insulin) percent and number of patients without a community health worker
Palliative Care
Percent and number of patients with reported pain score 0 or 1
Percent and number of patients with improvement of pain score since the last reporting period
Percent and number of patients prescribed morphine for symptom relief
Outcomes
Percent with HbA1c 8%
Percent and number with 3 or more hypoglycemic episodes in prior 3 months
Percent and number of patients hospitalized for diabetes
278 chronic care integration for endemic non-communicable diseases
Outcomes (continued)
Number of deaths in patients enrolled in the diabetes program in the last year
Data Quality
Percent and number of patients without an intake form
appendix c | indicators for monitoring and evaluation 279
C.5 Hypertension
Demographics
Percent male and female
Median age
Number of new patients enrolled during reporting period
Total number of patients at the end of reporting period
Total number of patients at the end of reporting period by district and sector
Diagnosis and Case-Finding
Of patients referred to NCD hypertension clinic, number/percent confirmed to have hypertension
Of patients with confirmed hypertension, number/percent with stage I HTN
Of patients with confirmed hypertension, number/percent with stage II HTN
Of patients with confirmed hypertension, number/percent with stage III HTN
Of patients with confirmed hypertension, number/percent with proteinuria
Of patients 40 years old, number/percent without a recorded creatinine
Of patients with stage III HTN (SBP 180 or DBP 110), number/percent without creatinine
Interventions
Number/percent of patients with proteinuria on ACE inhibitor (or have documented contraindication)
Of patients with Stage III hypertension, number/percent on 2 or more antihypertensives
Case-Holding/Retention
Percent and number of patients not seen in the last 6 months
Percent and number of patients not seen in the last 12 months
Palliative Care
Percent and number of patients with reported dyspnea score 0 or 1
Outcomes
Percent and number of patients with last recorded BP 140/90
Number of deaths in patients enrolled in the hypertension program in the last year
Data Quality
Percent and number of patients without an intake form
280 chronic care integration for endemic non-communicable diseases
C.6 Chronic Respiratory Disease
Demographics
Percent male and female
Median age
Number of new patients enrolled during reporting period
Total number of patients at the end of reporting period
Total number of patients at the end of reporting period by district and sector
Diagnosis and Case-Finding
Of patients referred to NCD respiratory clinic, the number/percent with confirmed chronic respiratory disease
Of patients enrolled in NCD respiratory clinic, number/percent with asthma/COPD
Of patients enrolled in NCD respiratory clinic, number/percent with brochiectasis
Of patients enrolled in NCD respiratory clinic, number/percent evaluated for tuberculosis with sputum analysis
Of patients referred for sputum analysis, the number/percent diagnosed with tuberculosis
Interventions
Of patients in NCD respiratory clinic, number/percent treated with salbutamol
Of patients in NCD respiratory clinic, number/percent treated with beclomethasone (any dose)
Of patients in NCD respiratory clinic, number/percent treated with aminophylline
Of patients in NCD respiratory clinic, number/percent treated with prednisone in the last 3 months
Case-Holding/Retention
Of patients in NCD respiratory clinic, number/percent not seen in the last 6 months
Of patients in NCD respiratory clinic, number/percent of patients with moderate or severe persistent classification not seen in the last 3 months
Palliative Care
Percent and number of patients with reported pain score 0 or 1
Percent and number of patients with reported dyspnea score 0 or 1
Percent and number of patients with improvement of pain score since the last reporting period
Percent and number of patients with improvement of dyspnea score since the last reporting period
Percent and number of patients prescribed morphine for symptom relief
Outcomes
Of patients in NCD respiratory clinic, number/percent who have improvement of severity classification over the last 6 months
appendix c | indicators for monitoring and evaluation 281
Outcomes (continued)
Of patients in NCD respiratory clinic, number/percent who have worsening of severity classification over the last 6 months
Of patients in NCD respiratory clinic, number/percent who have an “intermittent” classification
Data Quality
Percent and number without an intake form
282 chronic care integration for endemic non-communicable diseases
C.7 Epilepsy
Demographics
Percent male and female
Percent and number in age range ( 15, 15–24, 25–34, 35–44, 45–54, 55 or older)
Number of new patients enrolled during reporting period
Total number of patients at the end of reporting period
Total number of patients at the end of reporting period by district and sector
Diagnosis and Case-Finding
In the subgroup (onset 20 years old), number and percent checked for HIV and RPR
Number and percent in each diagnostic category (GTC-primary, GTC-secondary, GTC-not specified, focal, other)
Of patients referred to epilepsy clinic, number and percent thought to not have epilepsy
Interventions
Of patients on ARVs, number and percent on valproic acid
Of patients on valproic acid, number and percent with AST and ALT checked in last 12 months.
Case-Holding/Retention
Percent and number not seen in the last 6 months
Palliative Care
Percent and number of patients with reported pain score 0 or 1
Percent and number of patients with improvement of pain score since the last reporting period
Percent and number of patients prescribed morphine for symptom relief
Outcomes
Percent and number of patients without seizure in the last 3 months (adults and children)
Percent and number of patients with 2 seizures in the last 3 months (adults and children)
Percent and number of enrolled patients hospitalized for epilepsy in the last 3 months (adults and children)
Data Quality
Percent and number without an intake form
appendix dForms
,4%4'<4'-%&@)54'$'*$:-.)9A'&6'#84'6&%:*'"*45'#&'6&..&<'9&92+&:2:"9)+$3.4'5)*4$*4*'V`S(*X'$#'5)*#%)+#'8&*-)#$.*'$95'84$.#8'+49#4%*'$#'G?,2*"--&%#45'*)#4*')9';<$95$>'L..'6&%:*'8$@4'3'[%49+8'$95'U9A.)*8'#%$9*.$#)&9*>'H84*4'6&%:*'$%4'"*45'3'6&%'+.)9)+$.'$95':&9)#&%)9A'$95'4@$."$#)&9'-"%-&*4*>'H847'8$@4'A&94'#8%&"A8':$97'74$%*'&6'%4@)*)&9'#8%&"A8')9-"#'6%&:'$..'&6'#84'`S('+.)9)+)$9*>'H84*4'6&%:*'$%4'579$:)+'$95'"95&"3#45.7'<)..'+&9#)9"4'#&'+8$9A4'$*'#84'+8%&9)+'+$%4')9#4A%$#)&9'*#%$#4A7'4E-$95*'9$#)&9$..7>
L..'6&%:*'$%4'49#4%45'4.4+#%&9)+$..7')9#&'$9'4.4+#%&9)+':45)+$.'%4+&%5>'
2+)$9*'#&'%4-&%#'&9'-%&A%$:')95)+#&%*'V*44'APPENDIX CX>
D.1 Intake Forms
U$+8'5)*4$*4'6&..&<45')9'#84'`S('&%')9#4A%$#45'+8%&9)+'+$%4'+.)9)+*'8$*'$'+&%%4*-&95)9A')9#$P4'6&%:>'H84*4'6&%:*'A494%$..7'#$P4'/0':)9"#4*'#&'+&:-.4#4>'H84%4')*'*&:4'@$%)$#)&9')9')9#$P4'6&%:'.49A#8'3$*45'&9'#84'+&:-.4E)#7'&6'#84'5)*4$*4>'?9#$P4'6&%:*'$%4':4$9#'#&'34'%4-4$#45'4@4%7'Z':&9#8*'#&'/'74$%>
,4%4'<4'A)@4'$9'4E$:-.4'&6'$9')9#$P4'6&%:'"*45'6&%'84$%#'6$)."%4'-$#)49#*')9'#84'5)*#%)+#'`S('+.)9)+*>
1. History of present illness
A. Patient referred from: acute clinic hospital other clinic other_________________
B. Chief complaint _________________
C. Duration of symptoms ___ days /months / years
D. Ever hospitalized for these symptoms? yes no
Total number of hospitalizations: ____
E. Has the patient had:
dyspnea on exertion? yes no
orthopnea? yes no
If yes, does the patient sleep sitting because of orthopnea? yes no
F. Ever treated by a traditional healer for these symptoms ? yes no
Diagnosis: poisoning other_________________
Treatment: purgative other _________________
Cost: _________________FRW
G. If female: Did the symptoms start around delivery? n/a
yes no
If a woman between 15–45 years old, does she use birth
control?
If no, why__________
n/a
yes no
H. Does the patient have:
a. chronic cough (more than 3 weeks)? yes no
If yes : productive hemoptysis
b. night sweats that soak clothing? yes no
c. a large weight loss? yes no
If yes, how much? _____ kg or clothing is looser
I. Does the patient smoke? yes no past
If yes : traditional modern pipe ____ cigarettes or pipes/ day
J. Does the patient drink alcohol? yes no past
If yes : traditional _____ liters/ day modern_____ bottles/ day
Document any other relevant history:
284 chronic care integration for endemic non-communicable diseases
3. Past medical history
A. Has the patient ever had an HIV test ? yes no
If yes, result: positive negative Date of last test: ____/____/____
If positive: Last CD4:______ Date: ______/______/______
Enrolled in the IMB HIV program? yes no
B. Has the patient ever been treated for tuberculosis? yes no
If yes, how many times? _______________ In what year(s) ? _______________
C. Other history :
2. Previous outpatient medications
Is patient on cardiac medications at intake? yes no Never taken cardiac medications
Medication Dose Frequency Still taking?
furosemide ____ mg oral IV 1/d 2/d 3/d yes no
captopril
lisinopril ____ mg oral
1/d 2/d 3/d
yes no
aldactone ____ mg oral 1/d yes no
atenolol
carvedilol ____ mg oral
1/d 2/d
yes no
amlodipine
nifedipine ____ mg oral
1/d 2/d
yes no
digoxin ____ mg oral 1/d yes no
aspirin ____ mg oral 1/d yes no
warfarin ____ mg oral 1/d 2/d yes no
hydrochlorthiazide ____ mg oral 1/d yes no
methyldopa ____ mg oral 1/d 2/d 3/d yes no
isosorbide dinitrate
____ mg oral
1/d 2/d 3/d
yes no
hydralazine ____ mg oral 1/d 2/d 3/d yes no
prednisolone ____ mg oral 1/d 2/d yes no
penicillin V ____ mg oral 1/d 2/d 3/d yes no
benzathine penicillin 600,000 IU IM
1.2 M IU IM 1x/month 2x/month
yes no
______________ ____ mg oral IV 1/d 2/d 3/d yes no
Drug allergies ___________ yes no If yes, explain:_________________________
appendix d | forms 285
4. Social history
A. Occupation: unemployed retired farmer small child (< 5)
professional driver cleaner in school
school-aged,
not in school miner ____________
B. Too sick to work ? yes no
C. Civil status: married or lives with partner partner in prison
single or child divorced or separated
widow (partner died of:_________) orphan
D. Transport : foot bus bike taxi other
Cost of transport (round-trip)
Time to travel to health center
_______ FRW
_______ hrs
E. Socio-economic status:
The patient’s house has: _____ rooms _____ occupants
Does the patient’s family own a house? yes no
Roof is: tin thatch cement sheeting
The floor is: cement dirt
Does the patient’s family own land? yes no if yes: _________ hectares
Does the patient’s family have goats or cows? ______________ goats
__________ cows
How many children has the patient had or if a child, how many
siblings in the family? _____________________ children
Are all the children still alive? yes no
causes of death:________
Do all the school-aged children go to school? yes no N/A
Other social information:
5. Physical Exam
Vital signs:
BP: ______/_____ mmHg Pulse:_____ bpm Weight ______ kg Height ______ cm
Does the patient feel dizzy upon standing up? yes no
If indicated : RR: ______ SaO2: ____%
Normal Abnormal
General well-appearing
cachectic obese tachypneic
use of accessory muscles
HEENT JVP normal JVP high goiter
Lungs clear crackles (If yes, location:_________) wheezing
Heart PMI non-displaced
regular rhythm
no murmurs
tachycardia irregular rhythm PMI displaced
murmur 1 location :___________________________
systolic diastolic
murmur 2 location :___________________________
systolic diastolic
Abdomen soft non-tender
no hepatomegaly
no splenomegaly
no ascites
splenomegaly ____ cm hepatomegaly : ____ cm
pulsatile liver
ascites: mild moderate abundant
tenderness: RUQ LUQ RLQ LLQ
Extremities no peripheral edema
no joint pain or swelling
cold peripheral edema 1+ 2+ 3+
joints swollen joints
Neuro no abnormalities focal motor deficit
Other ___________________ ____________________________________________
286 chronic care integration for endemic non-communicable diseases
6. Previous labs (including today)
Date Results
1. ___/___/___
2. ___/___/___
3. ___/___/___
Chemistries point of care
Na: K: Cal: iCa : CO2: Urée: Créat: Glyc: Hgb:
4. ___/___/___
INR/ PT point of care
INR : PT :
7. Previous studies
Date Results
CXR __/__/__
normal
cardiomegaly
mild moderate
severe
Infiltrates (location:____________)
pleural effusions small big
(location:__________________)
EKG __/__/__ normal LVH atrial fibrillation infarction (location:_______________)
8. Preliminary echocardiographic result:
Left ventricular function
Normal mildly depressed markedly depressed
Ejection fraction estimate:_________ %
No mitral stenosis Mitral stenosis
Normal right ventricular size Large right ventricle
Normal IVC Large IVC
Other abnormalities ____________________________________________________________
9. Clinical Impression
A. Summary
B. Diagnosis
Heart Failure
Type of Heart Failure:
Cardiomyopathy
Rheumatic heart disease Mitral stenosis Other
Hypertensive heart disease
Other type of Heart Failure: ____________________________________
Severity of symptoms (If between categories, mark both)
NYHA class I (Asymptomatic) No limitation on activity
NYHA class I-II NYHA class II (Mildly symptomatic)
Symptoms only with moderate exertion, such as climbing a hill
NYHA class II-III
NYHA class III (Moderately symptomatic)
Symptoms with even light activity but comfortable at rest
NYHA class III-IV
NYHA class IV (Severely symptomatic)
Symptoms with all activities, may be symptomatic at rest
Renal Failure
Liver Failure
Other
C. Patient’s fluid status: hypervolemic euvolemic hypovolemic
appendix d | forms 287
10. Final plan
A. Labs, studies: VS HIV sputum x 3 Chest X-ray _____________________
Albumin SGOT SGPT
B. Medications
No medications MORNING NOON EVENING
Furosemide (Lasix) ____ mg ____ mg
Captopril ____ mg ____ mg ____ mg
Lisinopril ____ mg ____ mg
Aldactone ____ mg ____ mg
Carvedilol ____ mg ____ mg
Atenolol ____ mg ____ mg
Amlodipine ____ mg ____ mg
Nifedipine retard ____ mg ____ mg
Isosorbide dinitrate ____ mg ____ mg ____ mg
Hydralazine ____ mg ____ mg ____ mg
Hydrochlorothiazide ____ mg
Potassium (600 mg tab =
8mEq) ____ mg ____ mg
Prednisolone ____ mg ____ mg
Aspirin ____ mg
Warfarin ____ mg
Penicillin V ____ mg ____ mg
Benzathine penicillin
600,000 UI IM 1x/month 2x/month
Benzathine penicillin
1.2 M UI IM 1x/month 2x/month
C. Other medications: _____________________
D. Disposition Admit to hospital Discharge home
Follow-up ____/____/____
288 chronic care integration for endemic non-communicable diseases
EMR CLINIC Rwinkwavu Kirehe Butaro
Other:______________________________________
Change in clinic yes Date: ___/___/___ Clinic______________________________________________
EMR DEMOGRAPHICS EMR ADDRESS
Date of birth:___/___/___ Province: _____________
Age: District : _____________
Sex F M Secteur: _____________
Daily CHW: yes not indicated
Name : _______________________________
Cellule: _____________
Umudugudu: _____________
Change in CHW yes
Name :_________________ Date: ___/___/___
Telephone: _____________
patient other___________
If a child: Name of parent or guardian
______________________________
Change in address or
telephone: yes
Date: ___/___/___
Go to page 2 to change Telephone:_____________________________
CARDIAC DIAGNOSIS
Diagnosis or Problem EF
Date of
dx Type Clinician
__/__/__ preliminary
confirmed
__/__/__ preliminary
confirmed
NON-CARDIAC DIAGNOSIS AND PROBLEM LIST
EMR Diagnosis Date EMR Diagnosis Date
__/__/__ __/__/__
__/__/__ __/__/__
__/__/__ __/__/__
Cardiology consultation completed _____/_____/_____
Surgical candidate? yes no
If yes: Passport : yes not indicated
Visa : yes not indicated
appendix d | forms 289
D.2 Flowsheets
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8$*'$'+&@4%'*844#'<)#8'*"::$%7'$95'54:&A%$-8)+')96&%:$#)&9'#8$#')*'-.$+45'$#'#84'6%&9#'&6'#84'+8$%#>
D.2.1 Sample Cover Sheet
HOSPITALIZATIONS
EMR
Date of
admission
Date of
discharge Hospital Reason for hospitalization
___/___/___ ___/___/___
___/___/___ ___/___/___
___/___/___ ___/___/___
SOCIAL ASSISTANCE OR ASSESSMENT
EMR Date
Type of assistance or
assessment EMR Date
Type of assistance or
assessment
___/___/___ ___/___/___
___/___/___ ___/___/___
___/___/___ ___/___/___
(ex. Home visit, house construction, school financing, transport financing, food supplementation)
CHANGE IN CHW, ADDRESS OR TELEPHONE
EMR Date
___/___/___
___/___/___
___/___/___
NON-MEDICAL LIFE EVENTS SINCE DIAGNOSIS
EMR Date Event EMR Date Event
___/___/___ ___/___/___
___/___/___ ___/___/___
___/___/___ ___/___/___
(e.g. marriage, divorce, pregnancy, births, death of family members, change in socioeconomic status,
change in residence since diagnosis)
290 chronic care integration for endemic non-communicable diseases
D.2.2 Sample Events Flowsheet
RENDEZ-VOUS/ CLINIC VISIT
Date Wt BP P
NYHA
Class Hemodyn.
Missed any
meds ? Na K CO2 Cr Hgb INR
On birth
control ? F/up
2/2/10
50
90/
60 110 III
X hyper
eu
hypo
X yes
no
N/A 133 4 24 130 11 N/A
yes
X no
N/A 2/9/10
Comments :
2/9/10
45
100/
70 80 II
hyper
X eu
hypo
X yes
no
N/A
X yes
no
N/A 2/16/10
Comments :
CLINIC VISITS
Date
# times/week
awoken by
dyspnea
# puffs/week
of salbutamol
Peak
Flow
Good
inhaler
technique
Asthma
classification
not asthma
Activity
limitation due
to shortness of
breath Plan and Follow-up
_______ times _______ puffs
yes
no
brief
coaching
given
well-
controlled
moderately
controlled
poorly
controlled
daily or
almost daily
several times
per week
less than
once per week
not at all
RDV ___/___/___
group class :
___/___/___
step up treatment
continue the same
treatment
step down
treatment Comment :
CLINIC VISITS
Date Weight BP Pulse Proteinuria Na K CO2 Cr Missed insulin ?
yes no N/A
Glucose: Glucose today :___________________ fasting
Sx of low blood
sugar ? yes no When?: morning afternoon evening
Comments
appendix d | forms 291
D.2.3 Clinical Findings Flowsheet,4%4')*'$9'4E$:-.4'&6'8&<'#<&'%&<*'6%&:'#84'+.)9)+$.')95)+$#&%*'-$A4':)A8#'.&&P'6&%'$'#7-)+$.'84$%#'6$)."%4'-$#)49#>',4%4C'<4'*44'#84'-$#)49#'
@)*)#')9'#84'*4##)9A'&6':)**)9A'84%':45)+$#)&9*>'L'-&)9#2&62+$%4'+84:)*#%7'-$94.'<$*'5&94>'H84'-$#)49#'<$*'$.*&'9&#'&9'3)%#8'+&9#%&.>'b9'#84'94E#'@)*)#C')#')*'+.4$%'#8$#'#84'-$#)49#=*'@)#$.'*)A9*'$95'*7:-#&:'+.$**'):-%&@45'$95'*84'8$5'3449'#$P)9A'84%':45)+$#)&9*>'Y84'$.*&'8$5'3449'*#$%#45'&9'3)%#8'+&9#%&.>
6&%'*&:4'&6'#84'T%'5)*4$*4*'6&..&<45')9'#84'+.)9)+*>
D.2.3.1 Asthma
D.2.3.2 Diabetes
CLINIC VISIT
Date Wt BP P
NYHA
Class
Volume
Status
Missed
any
meds ? Na K Cr Hgb INR
On birth
control ? F/up
hyper
eu
hypo
yes
no
NA
yes
no
NA
Comments :
CLINIC VISIT
Date Weight BP Pulse Proteinuria Na K Cr F/up
Comments
MEDICATION LIST
Medication Dose Frequency Start date
Stop
date Reason for stopping
__/__/__ __/__/__
__/__/__ __/__/__
__/__/__ __/__/__
__/__/__ __/__/__
CLINIC VISIT
EMR Date
Number of
seizures
Missed
medications
Side effects If female: Plan
__/__/__
_________ seizures
None
Only with illness,
alcohol
yes
no
yes
no
On birth control:
yes no
Pregnant
No change
Change in médications
Labo/Labs EEG CTAllaitement/nursing
yes no
Comments:
RDV __/__/__
Clinicians
292 chronic care integration for endemic non-communicable diseases
D.2.3.3 Post-Cardiac Surgery
D.2.3.4 Hypertension
D.2.3.6 Medication Flowsheet
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D.2.3.5 Epilepsy
ASSESSMENT OF SYMPTOM MANAGEMENT (To be done at intake and as needed thereafter)
Ask the following questions with regard to the last 3 days
Have the patient rate their answer on a scale of 0 (none or not at all) to 5 (a lot or all the time).
Date __/__/__ __/__/__ __/__/__ __/__/__
1. Rate your pain
2a. Have any other symptoms been affecting how you
feel?
2b. If so, please rate each symptom:
Dyspnea
Nausea or vomiting
Constipation
Diarrhea
Incontinence
Pruritus
Fever
Weakness
Insomnia
Foul Odor
3. Have you been feeling worried about your illness?
4. Have you been able to share how you are feeling
with your family or friends?
5. Have you felt life was worthwhile?
6. Have you felt at peace?
7. Have you had enough help and advice for your
family to plan for the future?
If family is present:
8. How much information have you and your family
been given?
9. How confident has the family felt caring for the
patient?
10. Has the family been feeling worried about the
patient?
appendix d | forms 293
D.2.4 Palliative Care Flowsheet
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294 chronic care integration for endemic non-communicable diseases
Appendix D!References
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the pih guide to
Chronic Care Integration for Endemic Non-Communicable Diseases
rwanda edition
the pih guide toChronic Care Integration for Endem
ic Non-Com
municable D
iseasesrw
anda edition
Partners In Health
Harvard Medical School Department of Global Health and Social Medicine Program in Global Non-Communicable Disease and Social Change
Brigham and Women’s Hospital Division of Global Health Equity
Partners In Health is a 501(c)3 nonprofit corporation based in Boston, Massachusetts. Established in 1987, PIH is committed to making a preferential option for the poor by working with sister organizations to improve the health and well-being of people living in poor communities. To this end, PIH provides technical and financial assistance, medical supplies, and administrative support to partner projects in Haiti, Peru, Russia, Rwanda, Lesotho, Malawi, Mexico, Guatemala, Burundi, Kazakhstan, the Dominican Republic, and the United States. The goal of these partnerships is neither charity nor development but rather “pragmatic solidarity”— a commitment to struggle alongside the destitute sick and against the economic and political structures that cause and perpetuate poverty and ill health. Partners In Health is a!liated with the Division of Social Medicine at Harvard Medical School and the Division of Global Health Equity at the Brigham and Women’s Hospital.
More information on Partners In Health can be found at our web site: www.pih.org