Chronic Care Integration for Endemic Non-Communicable Diseases Non-Communicable Endemic for Integration Care Chronic the pih guide to the pih guide to Chronic Care Integration for Endemic Non-Communicable Diseases
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.
rwanda edition More information on Partners In Health can be found s66666 s66666 at our web site: www.pih.org
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 the pih guide to Chronic Care Integration for Endemic Non-Communicable Diseases
rwanda edition s66666 s66666
Partners In Health
Harvard Medical School Department of Global Health and Social Medicine Program in Global Non-Communicable Disease and Social Change
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!7'"*)9A'#8)*'A")54C'7&"'$+P9&<.45A4'$95'$A%44'#&'#84'#4%:*'&6'#8)*'9)+4> table of contents foreword xxiii ;464%49+4*' EE))) abbreviations xxv chapter 1 Integration of Chronic CareServices in Rwanda 1 />/' H84'F&9A'H$).'&6'U954:)+'`&92S&::"9)+$3.4'()*4$*4*')9';<$95$' / />J' L'[%$:4<&%P'6&%'Y#%$#4A)+'G.$99)9A'6&%'U954:)+' `&92S&::"9)+$3.4'()*4$*4' K />B' (4+49#%$.)^$#)&9'$95'?9#4A%$#)&9'&6'S8%&9)+'S$%4'' 6&%'`&92S&::"9)+$3.4'()*4$*4')9';<$95$' Z />K' _8)+8'S8%&9)+'()*4$*4*j' ] />0' H84'()*#%)+#',&*-)#$.'$*'$'Y&"%+4'&6'S.)9)+$.'F4$54%*8)-'' ] />Z' ()*#%)+#'?9-$#)49#'S$%4' /1 />]' ,4$.#8'S49#4%*W'S$*4'[)95)9AC'?9)#)$.'R$9$A4:49#C'' $95'S8%&9)+'S$%4' /1 />g' ;464%%$.'S49#4%*' // />d' b"#2&62S&"9#%7';464%%$.' /J />/1' Y+%449)9A' /J />//' G%)9+)-.4*'&6'G$#)49#'[&..&<2a-'$95';4#49#)&9W'S&::"9)#7'' ,4$.#8'_&%P4%*'$95'#84'U.4+#%&9)+'R45)+$.';4+&%5' /J />/J' UO")-:49#C'R45)+$#)&9'G%&+"%4:49#C'$95'S&*#*' /B ͳ᩸ ͳͶ chapter 2 Palliative Care and Chronic Care 17 J>/' ,)*#&%7'$95'G8).&*&-87'&6'G$..)$#)@4'S$%4'U66&%#*')9'' ;4*&"%+42G&&%'Y4##)9A*' /g J>J' S&::"9)#7',4$.#8'_&%P4%*'$95'S&::&9'G$..)$#)@4'S$%4'' ?9#4%@49#)&9*')9'#84'H%4$#:49#'&6'S8%&9)+'()*4$*4' /d J>J>/' L**4**:49#'&6'Y7:-#&:*' J1 J>J>J' Y7:-#&:'R$9$A4:49#' J/ J>J>B' G$)9' JJ J>J>B>/' `&+)+4-#)@4'G$)9' JJ J>J>B>J' `4"%&-$#8)+'G$)9' JJ J>J>B>B' G%)9+)-.4*'&6'G$)9'R$9$A4:49#' JB J>J>K' (7*-94$' J] J>J>0' `$"*4$i\&:)#)9A' J] viȀƢȀchronic care integration for endemic non-communicable diseases
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chapter 3 Role of Community Health Workers, Family Planning, Mental Health, and Social Services in the Treatment of Chronic Disease 33 B>/' S&::"9)#7',4$.#8'_&%P4%*' BB B>J' ,&"*)9A'L**)*#$9+4' BK B>B' `"#%)#)&9$.'Y"--&%#'' B0 B>K' R49#$.',4$.#8' B0 B>0' [$:).7'G.$99)9A')9'S8%&9)+'()*4$*4' B0 ͵᩸ ͵
chapter 4 Heart Failure 39 ͶǤͳ ϐ Ͷͳ ͶǤʹ ϐ Ͷʹ ͶǤ͵ ϐ Ͷ͵ K>B>/' H84'G$%$*#4%9$.'F&9A'LE)*'\)4<' KB K>B>J' H84'Y"3+&*#$.'\)4<' KK K>B>B' UD4+#)&9'[%$+#)&9'$95'[%$+#)&9$.'Y8&%#49)9A' K] K>B>K' L**4**:49#'6&%'R)#%$.'Y#49&*)*' Kg K>B>0' L**4**:49#'&6';)A8#',4$%#'Y)^4' Kd K>B>Z' L**4**:49#'&6'#84'?964%)&%'\49$'S$@$' 01 K>B>]' L**4**:49#'&6'G4%)+$%5)$.'U66"*)&9'' 01 K>K' ?9)#)$.';4+&A9)#)&9'$95';464%%$.'&6'#84',4$%#'[$)."%4'G$#)49#' 0/ ͶǤͷ ϐ ͷͷ K>Z' (4+&:-49*$#45',4$%#'[$)."%4' 00 K>]' [.")5'Y#$#"*'L**4**:49#' 0g K>]>/' T")54.)94*'6&%'?9)#)$#)9A'?9#%$@49&"*'()"%4*)*' Z/ K>]>J' T")54.)94*'6&%'?9)#)$#)9A'$95'H)#%$#)9A'b%$.'' ["%&*4:)54'$#',4$.#82S49#4%'F4@4.' ZJ K>]>B' T")54.)94*'6&%'a*4'&6'b#84%'()"%4#)+*' ZJ K>]>B>/' Y-)%&9&.$+#&94' ZB K>]>B>J' ,75%&+8.&%)$^)54' ZB K>]>K' ($9A4%*'&6'()"%4*)*' ZB K>g' S$%5)&:7&-$#87' ZK table of contentsȀƢȀvii
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chapter 5 Cardiac Surgery Screening, Referral, Anticoagulation, and Postoperative Management 107 0>/' ,)*#&%7'&6'S$%5)$+'Y"%A4%7')9';<$95$' /1] 0>/>/' b"#2&62S&"9#%7';464%%$.'#&'UE#4%9$.'S$%5)$+'' Y"%A)+$.'S49#4%*' /1d 0>/>/>/' G8).$9#8%&-)+'S49#4%*' /1d 0>/>/>J' [4426&%2Y4%@)+4'S49#4%*' //1 0>/>J' \)*)#)9A'S$%5)$+'Y"%A)+$.'H4$:*' //1 0>J' !").5)9A'$'`$#)&9$.'S$%5)$+'Y"%A4%7'G%&A%$:' /// 0>J>/' S$%5)$+'Y"%A)+$.';464%%$.' //J 0>J>J' G%)9+)-.4*'&6'S$*4'Y4.4+#)&9' //B 0>B' S&::&9'G%&+45"%4*'6&%'S$%5)$+'\$.@4*' //K 0>B>/' R)#%$.'&%'H%)+"*-)5'\$.@4';4-$)%' //0 0>B>J' G4%+"#$94&"*'G%&+45"%4*' //Z 0>B>B' R4+8$9)+$.'\$.@4*' //Z 0>B>K' !)&-%&*#84#)+'\$.@4*' //] 0>K' U$%.7'G&*#2b-4%$#)@4'U@$."$#)&9'V[)%*#'B'R&9#8*X' //] 0>K>/' ,4$%#'[$)."%4' //g 0>K>J' Y#4%9$.'_&"95'?964+#)&9'$95'(48)*+49+4' //g 0>K>B' G4%)+$%5)$.'H$:-&9$54' //d 0>K>K' U95&+$%5)#)*' //d 0>K>0' L#%)$.'L%%87#8:)$*' //d 0>0' b9A&)9A'R&9)#&%)9A'&6'#84'G&*#2b-4%$#)@4'G$#)49#' /J1 0>0>/' [4@4%')9'G$#)49#*'<)#8'G%&*#84#)+',4$%#'\$.@4*' /J1 0>0>J' \$.@4'H8%&:3&*)*' /JB 0>0>B' \$.@4'(48)*+49+4' /JK 0>Z' G49)+)..)9'G%&-87.$E)*'6&%'G$#)49#*'<)#8'Y"%A)+$..7'' S&%%4+#45';84":$#)+'\$.@".$%'()*4$*4' /JK 0>]' R4#8&5*'&6'L9#)+&$A".$#)&9'$95'?95)+$#)&9*' /JK 0>g' ?9)#)$#)9A'_$%6$%)9'H84%$-7' /JZ 0>g>/' S&9#%$)95)+$#)&9*'#&'_$%6$%)9'H84%$-7' /JZ 0>g>J' R&9)#&%)9A'_$%6$%)9' /J] table of contentsȀƢȀix
0>d' H)#%$#)9A'_$%6$%)9'H84%$-7' /Jd 0>/1' (%"A'Y"--.7'$95'G$#)49#'R&9)#&%)9A' /B/ 0>//' ($9A4%*'&6'L9#)+&$A".$#)&9' /BJ ͷ᩸ ͳ͵͵ chapter 6 Chronic Kidney Disease 135 Z>/' U#)&.&A7'&6'S8%&9)+'M)5947'()*4$*4')9';"%$.';<$95$' /B0 Z>J' Y+%449)9A'6&%';49$.'[$)."%4')9',)A82;)*P'G&-".$#)&9*' /BZ Z>J>/' ,7-4%#49*)&9' /BZ Z>J>J' ()$34#4*' /BZ Z>J>B' ,?\' /BZ Ǥ͵ ϐ ͳ͵ͺ Z>K' ?9)#)$.'U@$."$#)&9'$95'R$9$A4:49#'&6'S8%&9)+'M)5947'' ()*4$*4'VSM(X' /Bd Z>0' ,7-4%P$.4:)$' /K0 Z>Z' G$..)$#)@4'S$%4'6&%'S8%&9)+'M)5947'()*4$*4' /KZ Z>]' ;49$.';4-.$+4:49#'H84%$-7'V,4:&5)$.7*)*'$95'' G4%)#&94$.'()$.7*)*X' /Kg Z>g' ;49$.'H%$9*-.$9#$#)&9' /Kd Z>d' L+"#4'M)5947'[$)."%4')9',&*-)#$.)^45'G$#)49#*' /01 ᩸ ͳͷͳ chapter 7 Diabetes 153 Ǥͳ ϐ ' )9'L+"#4'S$%4',4$.#8'S49#4%'S.)9)+*' /00 ]>J' ;4+&A9)#)&9'$95'H%4$#:49#'&6'U:4%A49+7'Y#$#4*'' V,7-4%A.7+4:)$'$95',7-&A.7+4:)$X' /0g ]>J>/' ,7-4%A.7+4:)$' /0g ]>J>J' ,7-&A.7+4:)$' /Z1 ]>B' G%)9+)-.4*'$95'?9)#)$.'R$9$A4:49#'&6'()$34#4*' /Z/ ]>B>/' b%$.',7-&A.7+4:)+'LA49#*' /ZJ ]>B>J' G$#)49#'U5"+$#)&9' /ZK ]>K' R$9$A4:49#'&6'()$34#4*'<)#8'?9*".)9'H84%$-7' /Z0 ]>K>/' ?9)#)$#)&9'&6'?9*".)9'H84%$-7' /Zg ]>K>J' ?9*".)9';4A):49'Y4.4+#)&9' /Zg ]>0' ?9*".)9'a*4')9'#84'S&::"9)#7' /]/ ]>0>/' G%)9+)-.4*'&6'?9*".)9'L5D"*#:49#' /]B ]>Z' L5D"@$9#'H84%$-)4*'$95';&"#)94'R&9)#&%)9A'6&%'S&:-.)+$#)&9*'' )9'G$#)49#*'<)#8'()$34#4*' /]] ]>]' ()$34#4*'$95'G%4A9$9+7' /]d xȀƢȀchronic care integration for endemic non-communicable diseases
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chapter 11 Epilepsy Forthcoming
epilogue 255
appendix a Essential Equipment and Medicines 257 L>/' U**49#)$.'UO")-:49#' J0] L>J' U**49#)$.'R45)+)94*' J0] ᩸ ʹͲ
appendix b Cost Models 261 !>/' Y"::$%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'' VS$#+8:49#'L%4$W'B01C111X' JZB !>J>K' H$.'R$%A)9$.'S&*#*'G4%'S$-)#$' JZB !>B' S$%5)$+'Y"%A4%7' JZB !>B>/' S&*#'?9-"#*' JZB !>B>/>/' [&..&<2a-'S&*#'?9-"#*' JZB !>B>/>J' Y"%A)+$.'S&*#'?9-"#*'VL#'B11'S$*4*'G4%'c4$%X' JZK !>B>/>B' L@4%$A4'S$%5)$+'Y"%A)+$.'S&*#*'$*'$'["9+#)&9'' &6'#84'`":34%'&6'L99"$.'b-4%$#)&9*' JZK !>B>/>K' ;4A):49'$95'[&..&<2a-'S&*#*' JZ0 !>B>J' G&-".$#)&9'LA4'()*#%)3"#)&9'$95'S$*42[)95)9A' JZ0 !>B>B' H$.'R$%A)9$.'S&*#*'G4%'S$-)#$'VL#'B11'S$*4*'G4%'c4$%X' JZ0 !>K' Y+%449)9A'6&%',?\'`4-8%&-$#87' JZ0 !>K>/' S&*#'?9-"#*' JZ0 !>K>J' R$%A)9$.'[&..&<2a-'S&*#*' JZ0 !>K>B' G&-".$#)&9'LA4'()*#%)3"#)&9'$95'S$*42[)95)9A' JZZ !>K>K' H$.'R$%A)9$.'S&*#*'G4%'S$-)#$' JZZ !>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$.'S&*#*'G4%'S$-)#$' JZg table of contentsȀƢȀxiii
!>Z' ,7-4%#49*)&9'S&*#'R&54.*' JZg !>Z>/' S&*#'?9-"#*' JZg !>Z>J' L99"$.';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$.'S&*#*'G4%'S$-)#$' J]J appendix c Indicators for Monitoring and Evaluation 271 S>/' ,4$%#'[$)."%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 S>B' ;49$.'[$)."%4' J]K S>K' ()$34#4*' J]0 S>0' ,7-4%#49*)&9' J]] S>Z' S8%&9)+';4*-)%$#&%7'()*4$*4' J]g S>]' U-).4-*7' Jg1 appendix d Forms 281 (>/' ?9#$P4'[&%:*' Jg/ (>J' [.&<*844#*' Jg] (>J>/' Y$:-.4'S&@4%'Y844#' Jg] (>J>J' Y$:-.4'U@49#*'[.&<*844#' Jgg (>J>B' S.)9)+$.'[)95)9A*'[.&<*844#' Jgd (>J>B>/' L*#8:$' Jgd (>J>B>J' ()$34#4*' Jgd (>J>B>B' G&*#2S$%5)$+'Y"%A4%7' Jd1 (>J>B>K' ,7-4%#49*)&9' Jd1 (>J>B>0' U-).4-*7' Jd1 (>J>B>Z' R45)+$#)&9'[.&<*844#' Jd1 (>J>K' G$..)$#)@4'S$%4'[.&<*844#' Jd/ ᩸ ʹͻʹ xivȀƢȀchronic care integration for endemic non-communicable diseases
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chapter 1 [?Ta;U'/>/' H84'F&9A'H$).'&6'U954:)+'`S(*')9';<$95$' K [?Ta;U'/>J' a9)#*'&6'G.$99)9A'6&%'#84'F&9A2H$).'U954:)+'`S(*' 0 [?Ta;U'/>B' ?9#4A%$#)&9'&6',":$9';4*&"%+4*'6&%'S8%&9)+'S$%4' d
chapter 2 [?Ta;U'J>/' ()$A%$:'&6'G$..)$#)@4'S$%4'#8%&"A8&"#'#84'S&"%*4'' &6'?..94**'$95'!4%4$@4:49#'VL5$-#45'6%&:'_,bX' /] [?Ta;U'J>J' H84'_,b'H8%442Y#4-'G$)9'F$554%' JB
chapter 4 [?Ta;U'K>/' ()*#%)3"#)&9'&6'S$"*4*'&6',4$%#'[$)."%4')9'$' ;<$95$9'`S('+.)9)+'V9'l'/BKX' K1 [?Ta;U'K>J' G$%$*#4%9$.'F&9A'LE)*'\)4<' KB [?Ta;U'K>B' `&%:$.'G$%$*#4%9$.'F&9A'LE)*'\)4<'&9'' U+8&+$%5)&A%$-87'V()$*#&.4C'#&-h'Y7*#&.4C'3#&:X' KK [?Ta;U'K>K' Y"3+&*#$.'\)4<' K0 [?Ta;U'K>0' Y"3+&*#$.'\)4<'<)#8'`&%:$.'?\S'V#&-X'$95' ().$#45'?\S'V3#&:X' KZ [?Ta;U'K>Z' S$%5)&:7&-$#87')9'G$%$*#4%9$.'F&9A'LE)*'\)4<'' V()$*#&.4C'#&-h'Y7*#&.4C'3#&:X' Kg [?Ta;U'K>]' R)#%$.'Y#49&*)*')9'()$*#&.4' Kd [?Ta;U'K>g' ;)A8#'\49#%)+".$%'U9.$%A4:49#'VG$%$*#4%9$.'F&9A'\)4
chapter 5 [?Ta;U'0>/' ?95)+$#)&9'6&%'S$%5)$+'Y"%A4%7'34#<449'' `&@>'J11]'$95'[43>'J1/1'VmX' /1g [?Ta;U'0>J' Y&"%+4'&6'S$%5)$+'Y"%A4%7')9';<$95$'34#<449'' `&@>'J11]'$95'[43>'J1/1'V9X' /1g
chapter 6 [?Ta;U'Z>/' `&%:$.'M)5947'L9$#&:7'&9'a.#%$*&"95'!"##$%&'()*++ *&$%+,&'+-').//(#0+10#(-2)*3+(4)+*,(#+*&$%*+,&'++ $.,'#+5$#,'67' /KJ [?Ta;U'Z>J' a.#%$*&"95')9'S8%&9)+'M)5947'()*4$*4W'F&**'&6'' ()664%49#)$#)&9'34#<449'S&%#4E'$95'R45"..$' /KB table of contentsȀƢȀxv
[?Ta;U'Z>B' ,75%&94-8%&*)*'&9'a.#%$*&"95' /KK chapter 9 [?Ta;U'd>/' G%&A%4**)&9'6%&:'G8$%79A)#)*'#&';84":$#)+'[4@4%' J/d xviȀƢȀchronic care integration for endemic non-communicable diseases
Tables
chapter 1 HL!FU'/>/' !"%549'&6'`&92S&::"9)+$3.4'()*4$*4*')9';<$95$'F)9P45' #&'S&95)#)&9*'&6'G&@4%#7' J HL!FU'/>J' F4$5)9A'S$"*4*'&6'(4$#8'$95'()*$3).)#7')9';<$95$')9'' ()*$3).)#72L5D"*#45'F)64'c4$%*'V(LFc*X' B HL!FU'/>B' Y$:-.4'()*#%)+#',&*-)#$.k!$*45'S.)9)+)$9'Y+845".4' d
chapter 2 HL!FU'J>/' S&*#i?:-$+#'R$#%)E'&6'R45)+$.'?9#4%@49#)&9*C'' <)#8'UE$:-.4*' /d HL!FU'J>J' Y7:-#&:'L**4**:49#'Y+$.4'VL5$-#45'6%&:'#84'L6%)+$9' G$..)$#)@4'b"#+&:4*'Y+$.4X' J/ HL!FU'J>B' U**49#)$.'R45)+$#)&9*'6&%'G$)9';4.)46' JZ HL!FU'J>K' U**49#)$.'R45)+$#)&9*'6&%'S&9#%&.'&6'`$"*4$i\&:)#)9A' Jg HL!FU'J>0' U**49#)$.'H84%$-)4*'6&%'H%4$#)9A'S&9*#)-$#)&9' Jd HL!FU'J>Z' Y7:-#&:$#)+'R$9$A4:49#'&6'()$%%84$' B1 HL!FU'J>]' R$9$A4:49#'&6'S8%&9)+'G%"%)#"*'$95'YP)9'S$%4' B/
chapter 4 HL!FU'K>/' S$"*4*'&6',4$%#'[$)."%4';4-&%#45'37'Y4.4+#45'' U+8&+$%5)&A%$-8)+';464%%$.'S49#4%*')9'' Y"32Y$8$%$9'L6%)+$' Bd HL!FU'K>J' ?:-&%#$9#'()$A9&*#)+'S$#4A&%)4*')9',4$%#'[$)."%4' KJ ͶǤ͵ ϐ ' ,4$%#'[$)."%4' KB ͶǤͶ ϐ ' ,4$%#'[$)."%4' KB HL!FU'K>0' S&::&9'Y)A9*'$95'Y7:-#&:*'&6',4$%#'[$)."%4' Va*"$..7'G%4*49#')9'L55)#)&9'#&'Y8&%#94**'&6'!%4$#8X' 0J HL!FU'K>Z' `4<'c&%P',4$%#'L**&+)$#)&9',4$%#'[$)."%4'' ϐ ͷͷ HL!FU'K>]' Y)A9*'&6'(4+&:-49*$#45',4$%#'[$)."%4')9'L5".#*' 0Z HL!FU'K>g' ;4$*&9*'6&%'L+"#4'(4+&:-49*$#)&9')9'G$#)49#*'' <)#8',4$%#'[$)."%4' 0] HL!FU'K>d' \&.":4'Y#$#"*'S$#4A&%)4*'$95'()"%4#)+'L5D"*#:49#' 0d HL!FU'K>/1' ?9#%$@49&"*'["%&*4:)54'VF$*)EX'(&*)9A' Z/ HL!FU'K>//' UO")@$.49#'b%$.'$95'?\'["%&*4:)54'VF$*)EX'(&*4*' ZJ HL!FU'K>/J' b%$.'["%&*4:)54'VF$*)EX'(&*)9A' ZJ HL!FU'K>/B' b#84%'b%$.'()"%4#)+'(&*)9A' ZB HL!FU'K>/K' U#)&.&A7'&6'S$%5)&:7&-$#87')9';<$95$' ZK table of contentsȀƢȀxvii
HL!FU'K>/0' R&%#$.)#72;45"+)9A'R45)+$#)&9*'6&%'S$%5)&:7&-$#87' Z] HL!FU'K>/Z' ()A&E)9'(&*)9A' ]B HL!FU'K>/]' L9#)87-4%#49*)@4*'6&%',7-4%#49*)@4',4$%#'()*4$*4' ]Z HL!FU'K>/g' R45)+$#)&9*'#&';45"+4',4$%#';$#4')9'R)#%$.'Y#49&*)*' g1 HL!FU'K>/d' R45)+$#)&9*'6&%'\$.@".$%iS&9A49)#$.',4$%#'()*4$*4' g0 HL!FU'K>J1' S.)9)+$.'G%4*49#$#)&9'&6';)A8#2Y)545',4$%#'[$)."%4' g] HL!FU'K>J/' S$"*4*'&6';)A8#2Y)545',4$%#'[$)."%4' gg HL!FU'K>JJ' H%4$#:49#'&6'H"34%+".&"*'G4%)+$%5)#)*')9'L5".#*' dJ HL!FU'K>JB' S.)9)+'[&..&<2a-'Y+845".4'6&%',4$%#'[$)."%4'G$#)49#*' dZ chapter 5 HL!FU'0>/' H7-)+$.'G%4&-4%$#)@4'U@$."$#)&9'6&%'S$%5)$+'Y"%A4%7' //B HL!FU'0>J' H7-4*'&6'\$.@4';4-$)%*' //0 HL!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/ ͷǤͷ Ǧ ϐ ' \$.@4'U95&+$%5)#)*' /JB HL!FU'0>Z' S&::&9'(%"A'?9#4%$+#)&9*'<)#8'_$%6$%)9' /J0 HL!FU'0>]' L9#)+&$A".$#)&9'LA49#*'$95'?95)+$#)&9*' /JZ HL!FU'0>g' ?9)#)$.'b"#-$#)49#'_$%6$%)9'(&*)9A' /J] HL!FU'0>d' H84%$-)4*'[&%'!%)5A)9A'L9#)+&$A".$#)&9' /Jg HL!FU'0>/1' T494%$.'G%)9+)-.4*'&6'_$%6$%)9'H)#%$#)&9' /B1 chapter 6 HL!FU'Z>/' S$"*4*'&6'U952Y#$A4';49$.'()*4$*4')9'Y"32Y$8$%$9'' L6%)+$'$95'#84'a>Y>' /B0 HL!FU'Z>J' ;4.$#)&9*8)-'34#<449'a%)94'()-*#)+P'$95'JK28&"%'' a%)94'G%)9';4*".#*' /B] HL!FU'Z>B' Y#$A4*'&6'S8%&9)+'M)5947'()*4$*4' /Bd ǤͶ ϐ ǡ ' M)5947'()*4$*4' /KB HL!FU'Z>0' S&::&9'G87*)+$.'Y7:-#&:*')9'L5@$9+45'S8%&9)+'' M)5947'()*4$*4'$95'H84)%'H%4$#:49#' /K] HL!FU'Z>Z' S&::&9'G*7+8&.&A)+$.'Y7:-#&:*')9'L5@$9+45'' S8%&9)+'M)5947'()*4$*4'$95'H84)%'H%4$#:49#' /Kg chapter 7 HL!FU']>/' ()$34#4*'()$A9&*)*W'!.&&5'Y"A$%'R4$*"%4:49#'' $95'Y7:-#&:*' /0Z HL!FU']>J' ($9A4%'Y)A9*')9',7-4%A.7+4:)$' /0g HL!FU']>B' ?9*".)9'H84%$-7'&6'G$#)49#*'<)#8',7-4%A.7+4:)$'' ȋηʹͷͲȀȌ ͳͷͻ xviiiȀƢȀchronic care integration for endemic non-communicable diseases
HL!FU']>K' ()$A9&*)*'$95'H%4$#:49#'&6',7-&A.7+4:)$' /Z/ HL!FU']>0' T."+&*4'S&9#%&.'T&$.*' /ZJ HL!FU']>Z' b%$.',7-&A.7+4:)+'H84%$-7' /ZK HL!FU']>]' S&::&9'S$"*4*'6&%',7-4%A.7+4:)$')9'G$#)49#*'' &9'?9*".)9' /Z0 HL!FU']>g' ?95)+$#)&9*'6&%'?9*".)9'H84%$-7' /ZZ HL!FU']>d' G%&-4%#)4*'&6'?9*".)9'L@$).$3.4')9';<$95$' /Zd HL!FU']>/1' ?9*".)9';4A):49*' /]1 HL!FU']>//' UE$:-.4'&6'T."+&*4'R&9)#&%)9A'S8$%#' /]J HL!FU']>/J' G%)9+)-.4*'6&%'L5D"*#)9A'?9*".)9']1iB1'V826,'X'' &%'JEi5$7'`G,';4A):49*' /]0 HL!FU']>/B' G%)9+)-.4*'6&%'L5D"*#)9A'S&:3)945'!$*$.'V`G,X'' $95'G%$95)$.'V;4A".$%'?9*".)9X';4A):49*' /]0 HL!FU']>/K' UE$:-.4'&6'H%$9*)#)&9)9A'6%&:']1iB1'V94*./24'++ 826,(#)X'#&'`G,i;4A".$%'V94*./24'+:'4,''f';(12)'X' /]] HL!FU']>/0' S&::&9'S&:-.)+$#)&9*'&6'()$34#4*'$95'H84)%'' G%4@$.49+4')9'Y&:4'L6%)+$9'S&8&%#*' /]g
chapter 8 HL!FU'g>/' ,)A82;)*P'[4$#"%4*')9',7-4%#49*)&9' /dB HL!FU'g>J' ?9)#)$#)&9'&6',7-4%#49*)&9'H%4$#:49#'L++&%5)9A'#&'' Y#$A4'$95';)*P'[$+#&%*' /dg HL!FU'g>B' ;4+&::49545',7-4%#49*)&9'R45)+$#)&9*'$95'' (&*)9A'6&%'R&*#'L5".#'G$#)49#*' J11 HL!FU'g>K' ;4+&::49545'R45)+$#)&9*'6&%'R$9$A4:49#'&6'' ,7-4%#49*)@4'U:4%A49+7'VL5".#'(&*)9AX' J1/ HL!FU'g>0' ,7-4%#49*)&9'R45)+$#)&9*'$95'(&*)9A')9'' Y4##)9A'&6'G%)9"%)$'&%'R).5';49$.'[$)."%4'' VS%4$#)9)94'/11kJ11'n:&.iFX' J1J HL!FU'g>Z' ;4+&::49545',7-4%#49*)&9'R45)+$#)&9*'' $95'(&*)9A')9'Y4##)9A'&6'Y4@4%4';49$.'[$)."%4'' ȋηʹͲͲn:&.iFX' J1B HL!FU'g>]' S$"*4*'&6'Y4+&95$%7',7-4%#49*)&9' J1K HL!FU'g>g' ,7-4%#49*)@4'()*&%54%*'&6'G%4A9$9+7' J1d HL!FU'g>d' F&$5)9A'$95'R$)9#49$9+4'(&*)9A'&6'R$A94*)":'' Y".6$#4')9'U+.$:-*)$'$95'Y4@4%4'G%44+.$:-*)$'' VL5$-#45'6%&:'?RGLSX' J// HL!FU'g>/1' ;4+&::49545'R45)+$#)&9*'6&%'R$9$A4:49#'&6'' ,7-4%#49*)&9')9'Y4@4%4'G%44+.$:-*)$' J/J HL!FU'g>//' ;4+&::49545',7-4%#49*)&9'R45)+$#)&9*'$95'' (&*)9A')9'G%4A9$9+7' J/B
chapter 9 HL!FU'd>/' S.)9)+$.'(4+)*)&9';".4*'6&%'H%4$#:49#'&6'G8$%79A)#)*' JJ1 table of contentsȀƢȀxix
HL!FU'd>J' L9#)3))+';4A):49*'6&%'Y#%4-#&+&++$.'G8$%79A)#)*'' VL5".#*'$95'L5&.4*+49#*'(&*)9AC'_4)A8#'η'J]'PAX' JJJ HL!FU'd>B' L9#)3))+';4A):49*'6&%'Y#%4-#&+&++$.'G8$%79A)#)*'' VG45)$#%)+'(&*)9AC'_4)A8#'ζ'J]'PAX' JJJ ͻǤͶ ϐ Ǧ ʹʹ͵ HL!FU'd>0' L9#)3))+';4A):49*'6&%'Y4+&95$%7'G%&-87.$E)*'' &6';84":$#)+'[4@4%' JJ0 ͻǤ ϐ' G&**)3.4';,(')9'Y+8&&.2LA45'S8).5%49' JJ] HL!FU'd>]' U+8&+$%5)&A%$-8)+'[4$#"%4*'&6'F46#2Y)545',4$%#'' \$.@4*'H8&"A8#'S&9*)*#49#'<)#8';84":$#)+',4$%#'' ()*4$*4')9',)A82G%4@$.49+4'Y4##)9A*'37'H8%44'Y4#*' &6'S%)#4%)$' JJg ͻǤͺ ϐ ʹʹͻ chapter 10 HL!FU'/1>/' U@$."$#)&9'&6'L*#8:$'L##$+P'Y4@4%)#7'VL5$-#45'6%&:' ?aLHF('T")54.)94*X' JBg HL!FU'/1>J' S$"*4*'&6'S8%&9)+'(7*-94$'&%'S8%&9)+'S&"A8'' ȋη͵Ȍ ʹ͵ͻ HL!FU'/1>B' S&::&9'Y)A9*'$95'Y7:-#&:*'&6'L*#8:$' JK/ ͳͲǤͶ ϐ ʹͶʹ HL!FU'/1>0' 'L*#8:$'S&9#%&.'H4*#' JKB HL!FU'/1>Z' L*#8:$'Y#4-'H84%$-7' JKZ HL!FU'/1>]' L*#8:$'R45)+$#)&9'(&*)9A' JK] xxȀƢȀchronic care integration for endemic non-communicable diseases
Protocols
chapter 4 G;bHbSbF'K>/' ?9)#)$.'()$A9&*)*'$95'R$9$A4:49#'&6',4$%#'[$)."%4' 0K G;bHbSbF'K>J' R$9$A4:49#'&6'(4+&:-49*$#45',4$%#'[$)."%4' 0g G;bHbSbF'K>B' \&.":4'Y#$#"*'L**4**:49#'$95'()"%4#)+'L5D"*#:49#' Z1 G;bHbSbF'K>K' S$%5)&:7&-$#87'R$9$A4:49#' Z0 G;bHbSbF'K>0' !4#$2!.&+P4%'H)#%$#)&9')9'S$%5)&:7&-$#87' Zd G;bHbSbF'K>Z' LSU2?98)3)#&%'H)#%$#)&9'$95'a*4'&6'' ,75%$.$^)94i?*&*&%3)54')9'S$%5)&:7&-$#87' ]/ G;bHbSbF'K>]' b#84%'R45)+$#)&9'`445*'6&%'S$%5)&:7&-$#87'G$#)49#*' ]J ͶǤͺ ϐ' ,7-4%#49*)@4',4$%#'()*4$*4' ]0 G;bHbSbF'K>d' L9#)87-4%#49*)@4'R$9$A4:49#')9',7-4%#49*)@4'' ,4$%#'()*4$*4' ]] G;bHbSbF'K>/1' L**4**:49#'&6'R45)+$#)&9'S&9#%$)95)+$#)&9*'$95'Y)54'' U664+#*')9'R$9$A4:49#'&6',7-4%#49*)@4',4$%#'()*4$*4' ]g G;bHbSbF'K>//' R$9$A4:49#'&6'R)#%$.'Y#49&*)*' ]d G;bHbSbF'K>/J' \$.@".$%'&%'S&9A49)#$.',4$%#'()*4$*4'R$9$A4:49#'' VUE+."5)9A'R)#%$.'Y#49&*)*X' gB G;bHbSbF'K>/B' LSU2?98)3)#&%'H)#%$#)&9'6&%'\$.@".$%'&%'S&9A49)#$.'' ,4$%#'()*4$*4'R$9$A4:49#'VUE+."5)9A'R)#%$.'Y#49&*)*X' gK G;bHbSbF'K>/K' b#84%'R45)+$#)&9*'6&%'\$.@".$%'&%'S&9A49)#$.',4$%#'' ()*4$*4'R$9$A4:49#'VUE+."5)9A'R)#%$.'Y#49&*)*X' gZ G;bHbSbF'K>/0' R$9$A4:49#'&6'?*&.$#45';)A8#2Y)545',4$%#'[$)."%4' gd G;bHbSbF'K>/Z' [.")5'Y#$#"*'R$9$A4:49#')9';)A8#2Y)545',4$%#'[$)."%4' d1 G;bHbSbF'K>/]' ()$A9&*)*'$95'H%4$#:49#'&6'H"34%+".&*)*'G4%)+$%5)#)*' dB G;bHbSbF'K>/g' LSU2?98)3)#&%'$95'Y-)%&9&.$+#&94'H)#%$#)&9'$95'' G$%$+49#4*)*'6&%'?*&.$#45';)A8#2Y)545',4$%#'[$)."%4' dK G;bHbSbF'K>/d' b#84%'R45)+$#)&9'`445*')9'?*&.$#45';)A8#2Y)545'' ,4$%#'[$)."%4' d0 G;bHbSbF'K>J1' ()$A9&*)*'$95'R$9$A4:49#'&6'L#%)$.'[)3%)..$#)&9' dd G;bHbSbF'K>J/' G$.-)#$#)&9*' /11
chapter 5 G;bHbSbF'0>/' R$9$A4:49#'&6'[4@4%')9'G$#)49#*'<)#8'G%&*#84#)+'' ,4$%#'\$.@4*' /JJ G;bHbSbF'0>J' ?9)#)$#)9A'_$%6$%)9'H84%$-7' /Jg G;bHbSbF'0>B' H)#%$#)9A'_$%6$%)9'H84%$-7' /B/ table of contentsȀƢȀxxi chapter 6 G;bHbSbF'Z>/' ?9)#)$.'U@$."$#)&9'&6'S8%&9)+'M)5947'()*4$*4'' Y#$A4'/'&%'J' /Bd G;bHbSbF'Z>J' ?9)#)$.'U@$."$#)&9'&6'S8%&9)+'M)5947'()*4$*4'' Y#$A4'BC'KC'$95'0' /K/ G;bHbSbF'Z>B' b"#-$#)49#'R$9$A4:49#'&6'R).5',7-4%P$.4:)$' /K0 chapter 7 G;bHbSbF']>/' ()$A9&*)*'&6'()$34#4*'$95'R$9$A4:49#'&6'' ,7-4%A.7+4:)$'$#',4$.#82S49#4%'F4@4.' /0] G;bHbSbF']>J' H%4$#:49#'&6'()$34#4*'<)#8'b%$.',7-&A.7+4:)+'' LA49#*'V)9'L5".#*X' /ZB G;bHbSbF']>B' ?9)#)$#)&9'$95'L5D"*#:49#'&6'?9*".)9';4A):49*' /Z] chapter 8 G;bHbSbF'g>/' ?9)#)$.'Y+%449)9A'$95'R$9$A4:49#'&6',7-4%#49*)&9'' )9'L+"#4'S&9*".#$#)&9'S.)9)+*' /d/ G;bHbSbF'g>J' ?9)#)$.'R$9$A4:49#'&6'`4<.7';464%%45',7-4%#49*)&9'' S$*4*)9',4$.#8'S49#4%'?9#4A%$#45'S8%&9)+'S$%4'S.)9)+*' /dK G;bHbSbF'g>B' ?9)#)$.'()$A9&*)*'$95'R$9$A4:49#'&6'Y"*-4+#45'' Y4+&95$%7',7-4%#49*)&9' J1K G;bHbSbF'g>K' [&..&<2a-'\)*)#'6&%'S8%&9)+',7-4%#49*)&9')9',4$.#8'' S49#4%'?9#4A%$#45'S8%&9)+'S$%4'S.)9)+' J10 G;bHbSbF'g>0' R$9$A4:49#'&6',7-4%#49*)&9')9'G%4A9$9+7' J/1 chapter 9 G;bHbSbF'd>/' U@$."$#)&9'$95'R$9$A4:49#'&6'G8$%79A)#)*' JJ/ G;bHbSbF'd>J' Y+%449)9A'6&%';84":$#)+',4$%#'()*4$*4'V$95'b#84%'' S&95)#)&9*'&6'Y+8&&.2LA45'S8).5%49X' JJd chapter 10 G;bHbSbF'/1>/' ?9)#)$.'R$9$A4:49#'&6'S8%&9)+'S&"A8'&%'Y8&%#94**'' &6'!%4$#8'$#',4$.#8'S49#4%'L+"#4'S$%4'S.)9)+*' JB] G;bHbSbF'/1>J' ?9)#)$.'R$9$A4:49#'&6'L*#8:$'&%'SbG('$#'?9#4A%$#45' S8%&9)+'S$%4'S.)9)+*' JK/ G;bHbSbF'/1>B' [&..&<2a-'R$9$A4:49#'&6'L*#8:$'&%'SbG('' $#',4$.#82S49#4%'F4@4.' JKg foreword
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References
/' R$#84%*'SC'!&4%:$'HC'[$#'(R>'H84'T.&3$.'!"%549'&6'()*4$*4W'J11K'a-5$#4>' T494@$W'_&%.5',4$.#8'b%A$9)^$#)&9h'J11g> abbreviations
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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 Cervical cancer, gastric cancer, HPV, H. Pylori, EBV, HIV, Hepatitis B oncology4-7 lymphomas, Karposi’s sarcoma, hepatocellular carcinoma Breast cancer, CML Idiopathic, treatment gap
Hyperreactive malarial splenomegaly, Malaria hemoglobinopathies
Psychiatric8 Depression, psychosis, somatoform War, untreated chronic diseases, disorders 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 rwandaȀƢȀ3
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TABLE 1.2 Leading Causes of Death and Disability in Rwanda in Disability-Adjusted Life Years (DALYs)24
Disease DALYs Fraction of (’000) total DALYs Lower respiratory infections 843 15.6%
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% 74% Other infectious diseases (meningitis, 180 3.3% STDs excluding HIV, childhood-cluster diseases, upper respiratory infections, Hepatitis B, Hepatitis C) 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% 4ȀƢȀchronic care integration for endemic non-communicable diseases
FIGURE 1.1 The Long Tail of Endemic NCDs in Rwanda
Congenital anomalies
Unipolar depression
Asthma
Epilepsy Diabetes mellitus COPD Myocarditis Cervical cancer Lymphomas Rheumatic heart disease
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FIGURE 1.2 Units of Planning for the Long-Tail Endemic NCDs Health facilities
Referral centers Cardiac surgery Medical specialties Pathology (1 per 5–10 million people) Cancer center Surgical specialties Radiology
District hospitals (1 per 250,000 2nd-level acute care generalist physicians people) chronic care
Health centers Integrated (1 per 20,000 Integrated gynecology people) (benign and malignant)
Community health workers (1 per 200 people) 6ȀƢȀchronic care integration for endemic non-communicable diseases
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FIGURE 1.3 Integration of Human Resources for Chronic Care Health Workers Health facilities (Number per Facility)
Referral centers Specialist (1 per 5–10 physicians (1–2 per million people) specialty)
Neuro- District hospitals Generalist NCD HIV and psychiatric physicians nurses TB nurses (1 per 250,000 nurses (4–10) (2–3) (4–5) people) (2–3)
Health centers Integrated (1 per 20,000 chronic care people) nurses (2–3)
Community health workers Integrated chronic care (1 per 200 CHWs (2) people)
TABLE 1.3 Sample District Hospital–Based Clinician Schedule
Monday Tuesday Wednesday Thursday Friday
Nurse 1 Preceptorship Teaching District hospital Teaching Administration of health center (didactics) heart failure (didactics) nurses clinic and preceptorship Nurse 2 District hospital District hospital Teaching District hospital Teaching hematology/ chronic respiratory (didactics) advanced (didactics) oncology and disease and diabetes and preceptorship preceptorship hypertension clinic and preceptorship 10ȀƢȀchronic care integration for endemic non-communicable diseases
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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 ǡ ǡ ϐ $--&)9#:49#*>'_4'8$@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 ǡϐǦǡ )9'*&:4')9*#$9+4*'%464%%)9A'94<'&%'54+&:-49*$#45'+$*4*>'S&::"9)#7' Ǧϐ2 )9A'$+#)@)#)4*C')9'-$#)49#'45"+$#)&9C'$95')9'#84'-%&@)*)&9'&6'$+"#4C'+8%&9)+C' $95'-$..)$#)@4'+$%4'6&%'$'%$9A4'&6'+&95)#)&9*>'
T&&5'-$#)49#'6&..&<2"-'$.*&'%4.)4*'&9'$9'&%A$9)^45'*7*#4:'&6'%4+&%52 P44-)9A>';<$95$'8$*'$5&-#45'$9'4.4+#%&9)+':45)+$.'%4+&%5'*7*#4:'#&' *#&%4'-$#)49#')96&%:$#)&9C'#%$+P'@)*)#*C'$95':&9)#&%'+.)9)+$.'-%&A%4**>' S.)9)+)$9*'%4+&%5'@)*)#*'&9'*#$95$%5)^45')9#$P4'$95'6&..&<2"-'6&%:*' #8$#'+&..4+#'P47'-$#)49#'54:&A%$-8)+'$95'+.)9)+$.'+8$%$+#4%)*#)+*>'($#$' ϐ 6$+).)#$#4*'3'-$#)49#'6&..&<2"-'$95'-%&A%$:'4@$."$#)&9'$95':&9)#&%)9A>' chapter!1 | integration of chronic care services in rwandaȀƢȀ13
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1.12 Equipment, Medication Procurement, and Costs H84'_,b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h'#847'*8&".5'-%&@)54'+8%&9)+$..7' $5:)9)*#4%45':45)+$#)&9*'6%44'&%'$#':)9):$.'+8$%A4'#&'-$#)49#*'$#'#84' -&)9#'&6'+$%4>'APPENDIX B ϐ -%&A%$:'+&*#*'6&%'4$+8'+&95)#)&9> 14ȀƢȀchronic 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> B' R)9)*#%7'&6',4$.#8>'`$#)&9$.'`"#%)#)&9'Y"::)#';4-&%#>'?9@4*#)9A')9'`"#%)#)&9' $*'$'[&"95$#)&9'6&%'Y"*#$)9$3.4'(4@4.&-:49#')9';<$95$>'M)A$.)W'T&@4%92 :49#'&6';<$95$h'J1/1'[43%"$%7> K' G$%P)9'(RC'Y)#$*'[C'S8)%49D4'RC'Y#4)9'FC'L3%$##';C'_$3)9A$',>'G$%#'?W'S$9+4%'' )9')95)A49&"*'L6%)+$9*o3"%549C'5)*#%)3"#)&9C'$95'#%495*>'F$9+4#'b9+&.' J11ghdWZgB2dJ> 0' `4<#&9';C'`A).):$9$'GIC'T%".)+8'LC'4#'$.>'S$9+4%')9';<$95$>'?9#'I'S$9+4%' /ddZhZZW]02g/> Z' !45"2L55&'TC'!$#4*'?>'S$"*4*'&6':$**)@4'#%&-)+$.'*-.49&:4A$.7')9'T8$9$>' F$9+4#'J11JhBZ1WKKd20K> ]' _4$#84%$..'(IC'S.4AA'I!>'?984%)#45'8$4:&A.&3)9'5)*&%54%*W'$9')9+%4$*)9A' A.&3$.'84$.#8'-%&3.4:>'!"..'_&%.5',4$.#8'b%A$9'J11/h]dW]1K2/J> g ǡ Ǥ ǣϐ $A4>'ILRL'J1/1hB1BW/d]Z2]> d' Y)::*'\C'L#)D&*$9'bC'M"-4%',C'`"8"'LC';)*+84<*P)'(C'F$@7'S>'G%4@$.49+4'&6' 4-).4-*7')9';<$95$W'$'9$#)&9$.'+%&**2*4+#)&9$.'*"%@47>'H%&-'R45'?9#',4$.#8' J11gh/BW/1K]20B> /1' !)%34+P'TFC'R&.794"E'RUC'M$-.$9'G_C'4#'$.>'!.$9#7%4'R$.$%)$'G%&D4+#' U-).4-*7'Y#"57'V!RGUYX'&6'94"%&.&A)+$.'&"#+&:4*')9'%4#)9&-$#872-&*)#)@4' -$45)$#%)+'+4%43%$.':$.$%)$'*"%@)@&%*W'$'-%&*-4+#)@4'+&8&%#'*#"57>'F$9+4#' `4"%&.'J1/1hdW//]B2g/> //' U5<$%5*'HC'Y+#'LTC'R"97&P)'TC'4#'$.>'L+#)@4'+&9@".*)@4'4-).4-*7')9'$'%"%$.' 5)*#%)+#'&6'M497$W'$'*#"57'&6'-%4@$.49+4'$95'-&**)3.4'%)*P'6$+#&%*>'F$9+4#' `4"%&.'J11gh]W012Z> /J' S&::4%6&%5'GC'R$7&*)'!>'L9'$--%&-%)$#4'%4*4$%+8'$A495$'6&%'84$%#'5)*4$*4' )9'L6%)+$>'F$9+4#'J11ZhBZ]W/ggK2Z> /B' R&+":3)'LbC'[4%%4)%$'R!>'`4A.4+#45'+$%5)&@$*+".$%'5)*4$*4*')9'L6%)+$W' +8$..49A4*'$95'&--&%#"9)#)4*>'I'L:'S&..'S$%5)&.'J1/1h00WZg12]> /K' !"P8:$9'TC'q)4A.4%'IFC'G$%%7'U,>'U95&:7&+$%5)$.'[)3%&*)*W'*#)..'$':7*#4%7' $6#4%'Z1'74$%*>'?9W'GF&Y'`4A.4+#45'H%&-'()*h'J11gW4d]> /0' Y$.@)'YYC'!$%94*'GI>'S8%&9)+'&3*#%"+#)@4'-".:&9$%7'5)*4$*4')9'9&92*:&P4%*>' F$9+4#'J11dhB]KW]BB2KB> /Z' _8)#4'YFC'S8$53$9'YIC'I$9'YC'S8$-:$9'I;C'S$**'L>',&<'+$9'<4'$+8)4@4'A.&3$.' 4O")#7')9'-%&@)*)&9'&6'%49$.'%4-.$+4:49#'#84%$-7j'!"..'_&%.5',4$.#8'b%A$9' J11ghgZWJJd2B]> /]' R3$97$'ISC'R$.$'LLC'Y&39A<)'UC'L**$8'[MC'U9&%"'YH>'()$34#4*')9'' *"32Y$8$%$9'L6%)+$>'F$9+4#'J1/1hB]0WJJ0K2ZZ> /g' L#)D&*$9'bC';)*+84<*P)'(C'Y)::*'\C'4#'$.>'L'9$#)&9$.'*"%@47'&6':"*+".&*P4.2 4#$.'):-$)%:49#')9';<$95$W'-%4@$.49+4C'+$"*4*'$95'*4%@)+4'):-.)+$#)&9*>' GF&Y'b94'J11ghBW4Jg0/> /d' Y#$9.47'SRC';"#84%6&%5'T_C'R&%*845'YC'S&"A8.)9';;C'!474^$'H>'U*#):$#)9A' #84'84$.#8+$%4'3"%549'&6'&*#4&:74.)#)*')9'aA$95$>'H%$9*';'Y&+'H%&-'R45' ,7A'J1/1h/1KW/Bd2KJ> chapter!1 | integration of chronic care services in rwandaȀƢȀ15
J1' R$#849A4'_C'`P"%)P)74'IC'F):3"%A',C'M"-4%',>';$-)5'$**4**:49#'&6' ǣ ϐ Ǥ GF&Y'R45'J11]hKW4J/]> J/' G4#4%*49'GUC'!&"%A4&)*'(C'bA$<$',C'U*#"-)9$92($7'YC'`5)$74'S>'H84'A.&3$.' 3"%549'&6'&%$.'5)*4$*4*'$95'%)*P*'#&'&%$.'84$.#8>'!"..'_&%.5',4$.#8'b%A$9' J110hgBWZZ/2d> JJ' b34%:474%'qC';$D$%$#9$:'IMC'G$%P'S,C'4#'$.>'R4$*"%)9A'$5".#':&%#$.)#7'"*)9A' *)3.)9A'*"%@)@$.W'$'94<'$9$.7#)+$.':4#8&5'$95'94<'%4*".#*'6&%'KK'+&"9#%)4*C' /d]K2J11Z>'GF&Y'R45'J1/1h]W4/111JZ1> JB' I$:)*&9'(HC'_&%.5'!$9P>'()*4$*4'$95':&%#$.)#7')9'Y"32Y$8$%$9'L6%)+$>'' J95'45>'_$*8)9A#&9C'(>S>W'_&%.5'!$9Ph'J11Z> JK' R$#84%*'SC'!&4%:$'HC'[$#'(R>'H84'T.&3$.'!"%549'&6'()*4$*4W'J11K'a-5$#4>' T494@$W'_&%.5',4$.#8'b%A$9)^$#)&9h'J11g> J0' Y$:3'!C'U@$9*'HC'(73".'RC'4#'$.>'L9'$**4**:49#'&6')9#4%$+#)&9*'34#<449'A.&3$.' 84$.#8')9)#)$#)@4*'$95'+&"9#%7'84$.#8'*7*#4:*>'F$9+4#'J11dhB]BWJ/B]2Zd> JZ' ,^'GIC'[49<)+P'LC'Y$@)&.)'FC'R&.794"E'(,>';4*+")9A'#84'3#&:'3)..)&9' #8%&"A8'+&9#%&.'&6'94A.4+#45'#%&-)+$.'5)*4$*4*>'F$9+4#'J11dhB]BW/0]120> J]' ,^'GIC'($$%'LY>'H84'S`S(*'$95'#84'`H(*W'3."%%)9A'#84'.)94*'5)@)5)9A' 9&9+&::"9)+$3.4'$95'+&::"9)+$3.4'+8%&9)+'5)*4$*4*>'GF&Y'`4A.'H%&-'()*' J11ghJW4B/J> Jg' M49A4'LGC'Y&39A<)'UC'[4^4"'FC'4#'$.>'Y4##)9A2"-'9"%*42.45'-).'+.)9)+*'6&%'#84' :$9$A4:49#'&6'9&92+&::"9)+$3.4'5)*4$*4*'$#'-%):$%7'84$.#8'+$%4'.4@4.')9' %4*&"%+42.):)#45'*4##)9A*'&6'L6%)+$>'H84'G$9'L6%)+$9'R45)+$.'I&"%9$.'J11dhB> Jd' I$9**49*'!C'\$9'($::4'_C';$.4)A8'!C'4#'$.>'b664%)9A')9#4A%$#45'+$%4'6&%'' ,?\iL?(YC'5)$34#4*'$95'87-4%#49*)&9'<)#8)9'+8%&9)+'5)*4$*4'+.)9)+*')9' S$:3&5)$>'!"..'_&%.5',4$.#8'b%A$9'J11]hg0Wgg120> B1' S&.4:$9';C'T)..'TC'_).P)9*&9'(>'`&9+&::"9)+$3.4'5)*4$*4':$9$A4:49#')9' %4*&"%+42-&&%'*4##)9A*W'$'-%):$%7'+$%4':&54.'6%&:'%"%$.'Y&"#8'L6%)+$>'!"..' _&%.5',4$.#8'b%A$9'/ddgh]ZWZBB2K1> B/' Y8":3"*8&'[C'@$9'T%)49*@49'IC'F&<%$9+4'(C'4#'$.>'H$*P'*8)6#)9A'6&%'*+$.42"-' &6',?\'+$%4W'4@$."$#)&9'&6'9"%*42+49#4%45'$9#)%4#%&@)%$.'#%4$#:49#'$#'%"%$.' 84$.#8'+49#4%*')9';<$95$>'GF&Y'R45'J11dhZW4/111/ZB> BJ' F&<%$9+4'(_C'`5$:$A4'[C'M$7)%$9A<$'UC'4#'$.>'L5".#'+.)9)+$.'$95')::"9&2 .&A)+'&"#+&:4*'&6'#84'9$#)&9$.'$9#)%4#%&@)%$.'#%4$#:49#'-%&A%$:')9';<$95$' ʹͲͲͶȂʹͲͲͷǤ ϐ ʹͲͲͻǢͷʹǣͶͻǦͷͷǤ BB' ($9)4.*'`>'I"*#'84$.#8W':44#)9A'84$.#8'9445*'6$)%.7>'`4<'c&%PW'S$:3%)5A4' a9)@4%*)#7'G%4**h'J11g> BK' [4$+84:';TC'_&%.5'!$9P>'H84'84$.#8'&6'$5".#*')9'#84'54@4.&-)9A'<&%.5W'' $'*"::$%7>'_$*8)9A#&9C'(>S>W'_&%.5'!$9Ph'/ddB> B0' [$%:4%'GC'F4$95%4'[C'R"P84%D44'IYC'4#'$.>'S&::"9)#723$*45'$--%&$+84*'#&' ,?\'#%4$#:49#')9'%4*&"%+42-&&%'*4##)9A*>'H84'F$9+4#'J11/hB0gWK1K2d>
chapter 2 Palliative Care and Chronic Care
G$..)$#)&9')*'#84'$*-4+#'&6'84$.#8+$%4'+&9+4%945'<)#8'#84'-%4@49#)&9'$95' ϐ Ǥ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ϐ $95'-*7+8&*&+)$.'3"%549'&6')..94**')9'%"%$.'*"32Y$8$%$9'L6%)+$9'@)..$A4*>' ?9'#8)*'*4##)9AC'-$..)$#)&9'34+&:4*'$9'4**49#)$.'#$*P'6&%'#84'6$:).7'$95' #84'84$.#8'+$%4'-%&@)54%C'&94'#8$#'#4*#*'#84'.):)#*'&6'&"%'+&::)#:49#'#&' $9T%'-4%*&9=*'<4..234)9A>'G$..)$#)@4'+$%4'*8&".5'34'-%&@)545'#8%&"A82 &"#'#84'+&"%*4'&6'$'5)*4$*4'$95'9'D"*#'$#'#84'495'&6'$'-$#)49#=*'.)64'V*44' FIGURE 2.1ȌǤ Ǧ ϐ 54-495*'&9'#84'9$#"%4'&6'#84'"954%.7)9A'-$#8&.&A7>
FIGURE 2.1 Diagram of Palliative Care throughout the Course of Illness and Bereavement (Adapted from WHO)1
Disease-specific therapy
Palliative care Bereavement
Diagnosis Death
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2.1 History and Philosophy of Palliative Care E"orts in Resource-Poor Settings H&':$97C'-$..)$#)&9'8$*'34+&:4'*79&97:&"*'<)#8'4952&62.)64'+$%4>'H8)*' )*'34+$"*4C')9'<4$.#87'9$#)&9*C'-$..)$#)@4'+$%4'8$*'54@4.&-45'$*'$9'$.#4%2 Ǧϐ <)#8'$5@$9+45'5)*4$*4>'?#')*'&6#49'#84'-$#8'+8&*49'$#'#84'495'&6'$'.&9A' 3$##.4'<)#8'$9')..94**'$#'$'#):4'<849'$AA%4**)@4':4$*"%4*'#&'4E#495'.)64' +.4$%.7'*44:')9$--%&-%)$#4>
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L.#8&"A8'#84%4')*'9&'.&9A4%'543$#4'$3&"#'#84'9445'6&%'"9)@4%*$.'$++4**' #&'L;\*C'#84%4'$%4'*#)..':$97'#%4$#:49#*'6&%'9&92+&::"9)+$3.4'5)*4$*4*' #8$#'$%4'9'%4$5).7'$@$).$3.4')9'%4*&"%+42-&&%'*4##)9A*>'b6'+&"%*4C'#84%4' $%4'.):)#*>'L..':45)+$.')9#4%@49#)&9*'6$..'<)#8)9'$'*-4+#%":'3')9'#4%:*' ϐ Ǥ ϐǫǦ ǡ2 ϐ ϐ #84%4')*'$'*&+)4#$.'&3.)A$#)&9'#&'-%&@)54'#84:>'S&"9#%)4*'.)P4'#84'a9)#45' M)9A5&:'8$@4'$##4:-#45'#&'$9*<4%'#8)*'O"4*#)&9'#8%&"A8'6&%:$.'+&*#2 4664+#)@494**'$9$.7*4*'$95'8$@4'54@4.&-45'9$#)&9$.'A")54.)94*>/1'Y):).$%' 466&%#*'8$@4'3449'"954%#$P49'6&%'%4*&"%+42-&&%'*4##)9A*>// chapter!2 | palliative care and chronic careȀƢȀ19
L*'<4'8$@4'.4$%945'6%&:'#84'A.&3$.'4E-4%)49+4'<)#8'L;\*C')#')*'&6#49' -&**)3.4'#&'54+%4$*4'#84'-%)+4'&6'4664+#)@4'#84%$-)4*'#8%&"A8'$5@&+$+7' $95'+&..4+#)@4'3$%A$)9)9A>'H8)*'&3*4%@$#)&9'8$*':$54'4664+#)@494**'$' :&%4'):-&%#$9#'+%)#4%)&9'#8$9'+&*#')9'54#4%:)9)9A'#84'$--%&-%)$#4' *+&-4'&6'*4%@)+4*'6&%'$'-&-".$#)&9>'["%#84%:&%4C'#84'#$.'+&*#'&6'8)A82 ǡǦ ϐ [email protected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
TABLE 2.1 Cost/Impact Matrix of Medical Interventions, with Examples
High impact of therapy Low, marginal impact of therapy
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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%)+$9'*4##)9A*'V*44'TABLE 2.2X>/B'H84*4'O"4*#)&9*'<)..'9'34'$--.)+$3.4'6&%'$..'-$#)49#*'<)#8'+8%&9)+' chapter!2 | palliative care and chronic careȀƢȀ21
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TABLE 2.2 Symptom Assessment Scale (Adapted from the African Palliative Outcomes Scale)13
Questions for patient:
Q1. Please rate your pain during the last 3 days 0 (no pain) – 5 (worst/overwhelming pain)
Q2a. Have any other symptoms (e.g., nausea, coughing, or 0 (no, not at all) – 5 (overwhelmingly) constipation) been a#ecting how you feel in the last 3 days? Q2b. If so, please rate each symptom during the last 3 days: Dyspnea? 0 (no, not at all) – 5 (overwhelmingly) Nausea or vomiting? 0 (no, not at all) – 5 (overwhelmingly) Constipation? 0 (no, not at all) – 5 (overwhelmingly) Diarrhea? 0 (no, not at all) – 5 (overwhelmingly) Others? (specify) 0 (no, not at all) – 5 (overwhelmingly) Q3. Have you been feeling worried about your illness in the 0 (no, not at all) – 5 (overwhelming worry) past 3 days?
Q4. Over the past 3 days, have you been able to share how 0 (no, not at all) – 5 (yes, I’ve talked freely) you are feeling with your family or friends?
Q5. Over the past 3 days, have you felt that life was 0 (no, not at all) – 5 (yes, all the time) worthwhile?
Q6. Over the past 3 days, have you felt at peace? 0 (no, not at all) – 5 (yes, all the time)
Q7. Over the past 3 days, have you had enough help and 0 (no, not at all) – 5 (as much as wanted) advice for your family to plan for the future?
Questions for family caregiver:
Q8. Over the past 3 days, how much information have you 0 (none) – 5 (as much as wanted) and your family been given? N/A
Q9. Over the past 3 days, how confident has the family felt 0 (not at all) – 5 (very confident) caring for the patient? N/A
Q10. Has the family been feeling worried about the patient 0 (not at all) – 5 (severe worry) over the last 3 days? N/A
2.2.2 Symptom Management ϐ Ǥ &%':&%4'+&::&9C'5)*#%4**)9A'*7:-#&:*>'H84%$-)4*'$):45'$#'#84*4' ϐ #%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'$95'T%' 22ȀƢȀchronic care integration for endemic non-communicable diseases
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2.2.3 Pain G$)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
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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$9*'5"4'#&':4#$*#$*4*C' ϐǡ Ǥ
2.2.3.2 Neuropathic Pain `4"%&-$#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)$2 34#)+C'+$9+4%C'$95',?\iL?(Y'-$#)49#*>'L97'P)95'&6')9D"%7'#&'94%@4'#)**"4' ǡ ϐ #":&%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*#$@"5)94X> chapter!2 | palliative care and chronic careȀƢȀ23
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>+2 ?@A28!#00B180)2)"*&B#0=*0C2="%%0#+2U*+$.$#)9A'#84%$-7'6%&:'$'9&92 &-)&)5'V$+4#$:)9&-849i-$%$+4#$:&.C')3"-%&649C'&%'$*-)%)9X'#&'$'<4$P' ȋ ǦȌǡϐ 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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ϐǦ2 $#4'&%'*4@4%4'-$)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/increasing Strong opioid +/- non-opioid +/- adjuvant Moderate pain or pain persisting/increasing Weak opioid (or low-dose strong opioid) +/- non-opioid +/- adjuvant Mild pain Non-opioid (paracetamol or NSAID) +/- adjuvant 24ȀƢȀchronic care integration for endemic non-communicable diseases
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34'$5D"*#45'$#'*"3*4O"49#'@)*)#*'3$*45'&9'#84'-$#)49#=*'-$##4%9'&6' 3&<4.':&@4:49#*>'b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ϐ *.44->';4*-)%$#&%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.> 26ȀƢȀchronic care integration for endemic non-communicable diseases
TABLE 2.3 Essential Medications for Pain Relief
Symptom Medication Dose Notes
Mild pain/ Acetaminophen/ Adult: 0.5–1 gram Use maximum 2 grams per day in patients fever reducers paracetamol every 4 to 6 hours. with enlarged livers or known liver disease. (non-opiates) Not to exceed 4 Very toxic to liver in overdose. grams in 1 day Child: 10-15 mg/ kg (maximum 90 mg/kg/day divided every 4–6 hours) Ibuprofen Adult: 400–800 Particularly e#ective in bone pain. Anti- mg every 6-8 hours inflammatory at higher doses. Can cause (maximum dose 2.4 digestive upset and gastrointestinal bleeding. gm/day) Do not use in renal failure. Decrease doses in Child: 40 mg/kg/ patients with severe liver failure. Prolonged day every 6–8 prescription requires cimetidine or omepra- hours zole for gastrointestinal prophylaxis. Diclofenac Adult: 25–75 mg Same as ibuprofen, but less expensive for every 12 hours long-term use, with simpler dosing.
Moderate to Morphine, liquid Adult: 2.5–10 mg Dose increases may be limited by oversedation. severe pain preparation every 4 hours. May Should decrease the dose or increase the give double dose at dosing interval in case of any renal failure. bedtime. Constipation is a common problem and all No maximum dose. patients should be placed on a bowel regimen Titrate to patient prophylactically (see TABLE 2.5). comfort. Child: 0.15 mg/ kg–0.3 mg/kg every 4 hours. Titrate as with adults. Neuropathic pain Amitriptyline Adult: 10–25 mg by Dose should be titrated upward every week (burning pains or mouth daily. to e#ect. May take weeks to work. Maximum shooting) Child: 0.5 mg/ dose in adults is 100 mg per day. Side e#ects kg once a day include initial drowsiness, postural hypoten- orally at bedtime. sion, dry mouth, mild tachycardia, constipa- Increase as needed tion. Life-threatening cardiac toxicity with by 0.2–0.4 mg/kg overdose. every 2–3 days to maximum of 5 mg/ kg/day. Phenytoin Adult: 100 mg Can use instead of, or in addition to, amitrip- twice per day ini- tyline if neuropathic pain persists. Avoid if on tially, increase up to anti-retrovirals due to drug interactions. 400 mg twice per day if needed Child: 2.5–5 mg/ kg twice per day (maximum 200 mg twice per day) Muscle spasms Diazepam Adult: 2.5–10 mg Drowsiness, ataxia. by mouth 2 to 3 times per day Child: 0.05 mg/ kg–0.1 mg/kg 3 to 4 times per day chapter!2 | palliative care and chronic careȀƢȀ27
Symptom Medication Dose Notes Pain from Prednisolone Adult: 20–80 mg May also improve nausea, fatigue, and swelling, by mouth daily appetite. Particularly helpful in the case of inflammation, or Child: 1 mg/kg x malignant lesions causing localized swelling neuropathy 1–2x/day by mouth 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.
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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$)."%4C'#84'A"#'<$..*':$7'34+&:4'454:$#&"*'$95'6"9+#)&9'-&&%.7C'$'+&92 5)#)&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> 28ȀƢȀchronic 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, Haloperidol metabolic derangement, Adult: 0.5–1 mg 2–4 times per day given orally, IV, or SC, around the clock drug side e#ect, or bacterial or as needed infection (nausea due to a ζ toxin or inflammatory Child ( 40 kg): 0.025–0.05 mg/kg/day in 2–3 divided doses. Increase by mediator) 0.25–0.5 mg/day every 5–7 days as needed to maximum dose 0.15 mg/kg/day Promethazine Adult: 12.5–25 mg every 4 hours orally, IV, IM, or by rectum Child (ζ40 kg): 0.25–1 mg/kg 4 times a day orally, IV, IM, or by rectum. Maximum dose: 25 mg per dose Dexamethasone Adult: 4–10 mg 2 times per day IV or IM, around the clock or as needed Child (ζ 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 Dexamethasone pressure, bowel obstruction, Adult: 4–10 mg 2 times per day IV or IM, around the clock or as needed or distension of liver or of ζ hollow viscus due to neoplasm Child ( 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 Diazepam Adult: 2.5–10 mg 3 times per day, orally, IV, or SC, around the clock or as needed Child (ζ 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 Chlorpheniramine apparatus Adult: 4 mg orally every 4 hours, around the clock or as needed Child (ζ 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 Promethazine Adult: 12.5–25 mg every 4 hours orally, IV, IM, or by rectum Child: 0.25–1 mg/kg 4 times a day orally, IV, IM, or by rectum. Maximum dose: 25 mg Adjuvants for nausea/ Chlorpheniramine vomiting of any cause Adult: 4 mg orally every 4 hours, around the clock or as needed Child (ζ 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
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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..' ϐϐǡ2 $#45>'F$E$#)@4*'$95'494:$*':$7'$.*&'34'"*45'#&'4$*4'+&9*#)-$#)&9'V*44' TABLE 2.5X>'H84':&*#'+&::&9'#7-4*'&6'.$E$#)@4*'$%4'*#):".$9#*'V3)*$+&2 57.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')*' ϐǦǤ $%4'<4..'875%$#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"#>
TABLE 2.5 Essential Therapies for Treating Constipation
Treatment Dose
Glycerin suppository Adult: 4 gm suppository per rectum daily Child (ζ40 kg): 2 gm suppository per rectum daily Lactulose syrup Adult: 15–45 ml 2–3 times per day orally, maintain 30–90 ml/day Child (ζ40 kg): 7.5 ml 1 time per day orally Bisacodyl Adult: 10 mg once or twice daily, orally or per rectum Child (ζ40 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
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2.2.7 Diarrhea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ϐǤ
ϐ $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'$@$).$3.4> 30ȀƢȀchronic care integration for endemic non-communicable diseases
TABLE 2.6 Symptomatic Management of Diarrhea
Treatment Dose
Loperamide Adult: 4 mg orally initially, then 2 mg orally after every loose stool, up to a maximum of 16 mg per day Child (weight 13–20 kg): 1 mg orally 3 times per day Child (weight 21–30 kg): 2 mg orally up to 3 times per day Morphine, liquid preparation (low dose) Adult: 2.5 mg every 8 hours. May give orally, buccally, or rectally Child (ζ 40kg): 0.15 mg/kg, up to 2.5 mg every 4 hours. Administer as with adults Hyoscine butylbromide Adults: 10–20 mg every 6 hours orally or rectally
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TABLE 2.7 Management of Chronic Pruritus and Skin Care
Condition Treatment
Pruritus due to dry Emollient lotion such as calamine skin, renal failure Chlorpheniramine: Adult: 4 mg orally every 4 hours, around the clock or as needed Child (ζ 40 kg): 1–2 mg orally every 4 hours, around the clock or as needed Contact dermatitis Remove allergenic substance (e.g., from tape used High-potency topical steroid such as 0.05% betamethasone valerate in hospitals) Scabies Permethrin lotion applied from head (avoid face) to toes. Leave lotion on for 8–14 hours, then wash o#. The usual adult dose is 20–30 grams. Repeat in 1 week. Wash all clothes and bedding and dry in the sun. Do not use for babies less than 2 months old Cholestasis Adult: Prednisolone 10 mg per day. Cimetidine 400 mg twice per day.
Pruritus due to opioids Chlorpheniramine: Adult: 4 mg orally every 4 hours, around the clock or as needed Child (ζ 40 kg): 1–2 mg orally every 4 hours, around the clock or as needed Foul odor from wounds Keep wound clean. Crush metronidazole tables and sprinkle onto wound daily
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Chapter 2!References
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3.5 Family Planning in Chronic Disease !7'<&%P)9A'#&')9+%4$*4'84$.#8'6$+).)#7k3$*45'54.)@4%)4*'$95'$++4**'#&' -%49$#$.'+$%4C';<$95$'8$*'54+%4$*45')#*':$#4%9$.':&%#$.)#7'%$#4'6%&:' /K11':$#4%9$.'54$#8*'-4%'/11C111'.)@4'3)%#8*')9'J111'#&']01':$#4%9$.' 54$#8*'-4%'/11C111'.)@4'3)%#8*')9'J110>J'?9'*-)#4'&6'#84*4'):-%&@4:49#*C' -%4A9$9+7'$95'+8).53)%#8'*#)..'-&*4'$'8)A8'%)*P'&6':$#4%9$.':&%3)5)#7' $95':&%#$.)#7'#&'#84'<&:49'&6';<$95$'$95'T%'-&&%'+&"9#%)4*>' 36ȀƢȀchronic care integration for endemic non-communicable diseases
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Chapter 3!References
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chapter 4 Heart Failure
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TABLE 4.1 Causes of Heart Failure Reported by Selected Echocardiographic Referral Centers in Sub-Saharan Africa
Authors Country n Age† RHD. (%) DCM‡ (%) EMF§ (%) HTN HD†† (%) ICM‡‡ (%)
Amoah Ghana 572 42 115 (20) 65 (11) 22 (4) 122 (21) 56 (10) et al. 200019 Freers Uganda 406 N/A 58 (12) 40 (8) 99 (22) 38 (8) 4 (1) et al. 19969 Kingue Cameroon 167 57 41 (25)tt 46 (27) 5 (12) 91 (55) 4 (3) et al. 200520 Thiam Senegal 170§§ 50 76 (45)tt 12 (7) 0 (0) 58 (34) 30 (18) et al. 200221
† Age = Mean Age; * RHD = Rheumatic heart disease; ‡ DCM = Dilated cardiomyopathies; § EMF = Endomyocardial fibrosis; †† HTN HD = Hypertensive heart disease; ‡‡ ICM = Ischemic cardiomyopathy tt These series reported total valvulopathies. §§ Patients were double counted if they had two etiologic processes.
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FIGURE 4.1 Distribution of Causes of Heart Failure in a Rwandan NCD clinic (n = 134)
Rheumatic heart disease 33% 8%
13% Cardiomyopathy 41% 3%
2%
Cardiomyopathy Rheumatic heart disease Hypertensive heart disease Other Congenital heart disease Cor pulmonale
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TABLE 4.22.)*#*'#84'+$#4A&%)4*'&6'84$%#'6$)."%4'):-&%#$9#'6&%':45)+$.' :$9$A4:49#'$#'#84'5)*#%)+#'8&*-)#$.'.4@4.>'?9'#84'6&..&<)9A'*4+#)&9*C'<4' ǡϐǡ ϐǡ *4+&95C'8&<'#&':$9$A4'4$+8'+$#4A&%7'&6'84$%#'6$)."%4> 42ȀƢȀchronic 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 breath 3. Normal to mildly depressed left ventricular function (ejection fraction η 40%) 3. Mitral stenosis
Diagnostic criteria 1. Mitral valve that doesn’t open well with typical hockey-stick or elbow deformity 2. Normal to mildly depressed left ventricular function (ejection fraction η 40%) 4. Other valvular heart disease (including rheumatic and congenital)
Diagnostic criteria 1. Normal to mildly depressed left ventricular function (ejection fraction η 40%) 2. No mitral stenosis 3. Blood pressure ζ 180/110 mmHg 4. Dramatic heart murmur 5. Isolated right heart failure
Diagnostic criteria 1. Ejection fraction η 40% 2. No mitral stenosis 3. Blood pressure ζ 180/110 mmHg 4. No heart murmur 5. Large right ventricle or dilated inferior vena cava on echocardiography
4.2 Physical Exam Findings for Classification of Heart Failure ϐǤ b"%'5)$A9&*#)+'$.A&%)#8:*'"*4'&9.7'3.&&5'-%4**"%4'$95'#84'-%4*49+4'&6' Ǥϐǡ ϐǡ ǡ ǡ2 #$9#')9'54#4%:)9)9A':45)+$#)&9'$5D"*#:49#*'$95'5)*-&*)#)&9'<)#8)9'4$+8' 5)$A9&*#)+'$.A&%)#8:>
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TABLE 4.3 Physical Exam Findings in Classification of Heart Failure
1. Dramatic murmurs 2. Blood pressure η 180 mmHg systolic or 110 mmHg diastolic
4.3 Echocardiography for Classification of Heart Failure ϐ &6'84$%#'6$)."%4>'b"%'5)$A9&*#)+'$95'#%4$#:49#'$.A&%)#8:*'%4.7'&9'#84'+.)2 9)+)$9=*'$3).)#7'#&':$*#4%'#<&'4+8&+$%5)&A%$-8)+'@)4<*'&6'#84'84$%#W'#84' -$%$*#4%9$.'.&9A'$E)*'@)4<'$95'#84'*"3+&*#$.'@)4<'V*44'34.&
TABLE 4.4 Echocardiographic Findings in Classification of Heart Failure
1. Moderately to severely decreased EF (u 40%) 2. Mitral stenosis 3. Very large right ventricle (much larger than the aortic root or left atrium) 4. Clearly enlarged and non-collapsing vena cava (η 2.5 cm)
4.3.1 The Parasternal Long Axis View H84'-$%$*#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'$95'FIGURE 4.3X>
FIGURE 4.2 Parasternal Long Axis View
Right ventricle
Aortic root
Left ventricle Left atrium
Mitral valve Mitral valve (anterior leaflet) (posterior leaflet) 44ȀƢȀchronic care integration for endemic non-communicable diseases
FIGURE 4.3 Normal Parasternal Long Axis View on Echocardiography (Diastole, top; Systole, bottom)
Right ventricle
Left ventricle in diastole
Aortic root
Left atrium
Mitral valve Mitral valve (posterior leaflet) (anterior leaflet)
Left ventricle in systole
Closed mitral valve
4.3.2 The Subcostal View H84'*"3+&*#$.'@)4<')*'&3#$)945'<)#8'#84'-%&34'-.$+45'"954%'#84'E)-8&)5' Ǥϐǡ #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#%$9+4')9#&'#84'%)A8#'@49#%)+.4>' chapter!4 | heart failureȀƢȀ45
FIGURE 4.4 Subcostal View
Liver
Tricuspid valve Right ventricle
Right atrium
Left Inferior vena cava (IVC) ventricle Left atrium
Mitral valve 46ȀƢȀchronic care integration for endemic non-communicable diseases
FIGURE 4.5 Subcostal View with Normal IVC (top) and Dilated IVC (bottom) Liver Inferior Tricuspid Right valve vena cava Right atrium ventricle (IVC)
Left ventricle
Mitral valve
Left atrium
Dilated Liver inferior vena cava (IVC)
Right atrium
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FIGURE 4.6 Cardiomyopathy in Parasternal Long Axis View (Diastole, top; Systole, bottom)
Right ventricle Left ventricle in diastole Aortic root
Left atrium
Mitral valve Mitral valve (anterior leaflet) (posterior leaflet)
Left ventricle in systole
Closed mitral valve
4.3.4 Assessment for Mitral Stenosis ?9'-$#)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'$95' FIGURE 4.6 ȌǢȋʹȌϐ 8$*'$'8&+P47'*#)+P'&%'4.3&<'546&%:)#7h'VBX'.46#'@49#%)+".$%'6"9+#)&9')*' #7-)+$..7'9&%:$.>' chapter!4 | heart failureȀƢȀ49
FIGURE 4.7 Mitral Stenosis in Diastole
Right ventricle
Left ventricle
in diastole Aortic root
Left atrium
Mitral valve Small opening (anterior leaflet of stenotic mitral valve in diastole with hockey stick or elbow deformity)
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FIGURE 4.8 Right Ventricular Enlargement (Parasternal Long View)
Right ventricle (very dilated in diastole) 50ȀƢȀchronic care integration for endemic non-communicable diseases
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FIGURE 4.9 Pericardial E"usion (Parasternal View, top; Subcostal View, bottom)
Large pericardial e!usion Left ventricle
Large pericardial e!usion Liver
Left atrium
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ϐTABLE 4.5'V*44'34.&
TABLE 4.5 Common Signs and Symptoms of Heart Failure (Usually Present in Addition to Shortness of Breath)
1. Lower-extremity edema 2. Loud murmurs 3. Orthopnea (shortness of breath when lying prone)
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PROTOCOL 4.1 Initial Diagnosis and Management of Heart Failure
Suspected or confirmed heart failure
Treat as Signs of decompensated decompensated Echo-confirmed YES NO heart failure heart failure? heart disease? (Protocol 4.2) (Table 4.7) (Section 4.3)
NO YES
Ultrasound available? Follow appropriate treatment protocol YES according to diagnosis (Protocols 4.3–4.18) NO Abnormal Treat as left ventricular YES cardiomyopathy function? (Protocol 4.4)
NO
≥ Mitral Treat as mitral BP 180/110 NO YES stenosis? stenosis mmHg (Protocol 4.11)
NO Treat as valvular/ Murmur YES congenital disease YES (Protocol 4.12)
NO Treat as hypertensive heart disease Large, Signs Treat as (Protocol 4.8) non-collapsing of right- right-sided YES IVC or very YES sided heart heart failure large right failure (Protocol 4.15) ventricle NO NO
Consider alternate diagnoses
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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' ϐǤ 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> 56ȀƢȀchronic care integration for endemic non-communicable diseases
TABLE 4.7 Signs of Decompensated Heart Failure in Adults
Vital signs Blood pressure Very low (SBP ζ 80 mmHg) Very high (SBP η 180 mmHg)
Pulse Very low (ζ 40 bpm) Very high (η120 bpm)
High respiratory rate η 24 breaths/minute
Low oxygen saturation Saturation ζ 90%
Symptoms Inability to lie down flat Severe dyspnea at rest
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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. Pregnancy Exacerbates all types of heart failure, but especially mitral stenosis (2nd and 3rd trimester) and peripartum cardiomyopathy. 7. Arrhythmia Especially common in patients with cardiomyopathies and valvular disease, particularly mitral stenosis. 8. Worsened hypertension Very high blood pressure can cause acute sti#ening of the heart muscle and back up of fluid into the lungs (pulmonary edema). 58ȀƢȀchronic care integration for endemic non-communicable diseases
PROTOCOL 4.2 Management of Decompensated Heart Failure
Signs of Decompensated Place IV, hospitalize or Heart Failure prepare for transfer to (Table 4.7) hospital
Lower blood ≥ pressure BP 180/110 YES mmHg? (see Table 8.4, Section 8.4)
NO
Obtain YES HR ≥ 120 ECG
NO
Signs of atrial Look for other Signs of fluid fibrillation (irregularly reasons for NO overload NO decompensation and spaced QRS and/or (Table 4.9) no P waves) treat accordingly
YES YES
Initial furosemide dose Load with (Table 4.10 ) digoxin, start anticoagulation (see Section 4.16.1) Dose Diuresis after Diuresis within NO escalation 1–2 dose 30 minutes? (Table 4.10) escalations?
YES NO
Check Treat according creatinine, to diagnosis consider (Sections 4.8–4.12) alternative diagnosis
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TABLE 4.9 Volume Status Categories and Diuretic Adjustment
Category Hypovolemic Euvolemic Hypervolemic
Mild Moderate Severe (decompensated)
Weight Less than At dry weight ζ 5 kg above η 5 kg above dry η 5 kg above dry dry weight dry weight weight weight
Symptoms Variable Class I–II Class I–II Class II–III Class III–IV
Vital signs Tachycardia Normal Normal Mild tachycardia Tachycardia, tachypnea, Hypotension hypoxia, hypotension, or hypertension Physical Does not always correlate with severity. Signs of fluid overload include distended neck veins, exam 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 Stable or Can be increased (due to hypoperfusion of decreased decreased the kidneys), stable or decreased.
Diuretic Stop all Reduce or Maintain or Increase dose Start IV furosemide adjustment diuretics maintain dose increase or add second and prepare for (if starting beta- dose agent transfer to hospital if blocker, do not possible reduce diuretic) 60ȀƢȀchronic care integration for endemic non-communicable diseases
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PROTOCOL 4.3 Volume Status Assessment and Diuretic Adjustment
Suspected or confirmed heart failure
Perform volume assessment
Hypervolemia Hypovolemia Euvolemia
Mild Moderate Severe Stop all diuretics, consider giving fluids Maintain OR Increase increase IV diuresis, diuretic hospitalize diuretic dose dose Low EF AND starting or increasing beta-blocker dose
YES NO
Decrease OR Maintain maintain diuretic diuretic dose dose chapter!4 | heart failureȀƢȀ61
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TABLE 4.10 Intravenous Furosemide (Lasix) Dosing
Initial dosing Escalation Maximum dose Patient does not already Adult: Double every 30 minutes Adult: take furosemide 40 mg IV 2x–3x/day until response or maximum 100 mg IV 2–3x/day dose achieved Pediatric (ζ 40 kg): Pediatric: 0.5 mg/kg IV 2x/day 2 mg/kg 2–3x/day Patient already takes Double e#ective outpatient furosemide dose and give as IV 62ȀƢȀchronic care integration for endemic non-communicable diseases
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TABLE 4.11 Equivalent Oral and IV Furosemide (Lasix) Doses
Oral IV
80 mg PO 40 mg IV
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TABLE 4.12 Oral Furosemide (Lasix) Dosing
Initial dose Dose adjustment Maximum dose Hypovolemia Euvolemia Mild Moderate Severe hypervolemia hypervolemia hypervolemia
Adult: Stop all May attempt Keep dose Double current Admission and Adult: 40 mg diuretics, to decrease the same dose or add intravenous 80 mg 1x/day consider dose unless second agent diuresis (see 2x/day giving fluid starting or TABLE 4.10) Pediatric: increasing Pediatric: 1 mg/kg beta-blocker 2 mg/kg 1x/day 2–3x/day
4.7.3 Guidelines for Use of Other Diuretics b#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 failureȀƢȀ63
4.7.3.1 Spironolactone Y-)%&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'-$#)49#*'*8&".5'%4O")%4'#8)*>'H8)*'+&:2 3)9$#)&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' $95'<)#8'@4%7'+.&*4':&9)#&%)9A'&6'4.4+#%&.7#4*>
TABLE 4.13 Other Oral Diuretic Dosing
Drug Initial dosing Notes Maximum dose Spironolactone Adult: 25 mg 1x/day Add if patient has significant ascites 50 mg/day and normal renal function Pediatric (ζ 40 kg): 3 mg/kg/day 2.5 mg/kg 1x/day Hydrochlorothiazide Adult: 12.5 mg 1x/day Can be used if furosemide is not 25 mg/day available or added to furosemide if Pediatric (ζ 40 kg): 12 mg/day greater diuresis is desired. 1 mg/kg/day
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TABLE 4.14 Etiology of Cardiomyopathy in Rwanda
Idiopathic Most of the cases of cardiomyopathy are caused by an unknown process. Many may be due to a previous viral infection.
HIV cardiomyopathy HIV can cause direct cellular damage to heart muscle. ARVs can delay or reverse this process.
Alcohol-related Chronic alcohol use can be toxic to the heart muscle. If the patient stops drinking cardiomyopathy alcohol, the function may improve with time.
Peripartum Women can develop a cardiomyopathy in the last month of pregnancy and up to six months postpartum. This often improves with appropriate management and avoidance of subsequent pregnancies. Viral myocarditis Many di#erent viruses can infect the heart muscle and cause dysfunction. This often improves with time, but may be permanent.
Anemia Severe anemia (sometimes due to cancer or poor nutrition) can lead to cardiomyopathy. This can improve when the anemia is treated.
Advanced valvular Most valvular conditions causing abnormal flow of blood within the heart can lead disease to a cardiomyopathy. This is particularly true with regurgitant lesions. This is not the case for pure mitral stenosis, in which the left ventricle is protected, while the right ventricle ultimately su#ers.
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chapter!4 | heart failureȀƢȀ65
L..'+$%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
Ejection fraction ≤ 40%
Assess vital signs, treat decompensated heart failure (Protocol 4.2)
Assess fluid status, adjust furosemide (Protocol 4.3, Tables 4.9 and 4.12)
Adjust heart failure beta-blocker (Protocol 4.5)
Assess renal function and potassium, adjust ACE inhibitor OR hydralazine/isosorbide (Protocol 4.6)
Assess other medication needs (Protocol 4.7)
Follow-up planning (Section 4.13, Table 4.23)
4.8.1 Vital Sign Assessment L*')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> 66ȀƢȀchronic care integration for endemic non-communicable diseases
4.8.2 Fluid Status Assessment H84'94E#'*#4-')9'#84':$9$A4:49#'&6'+$%5)&:7&-$#87')*'4@$."$#)&9'&6' ϐ Ǥ ǡ 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' Ǧ ϐǤ
4.8.3 Titration of Mortality-Reducing Medications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ǯǦ ϐǤ Ǧ ǡ ϐǤ 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 failureȀƢȀ67
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.
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#$23.&+P4%':&*#'&6#49'$@$).$3.4')9'.&<2%4*&"%+4'*4#2 Ǥ ϐ J11g'_,b':&54.'5%"A'6&%:".$%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' ϐ ȋǦ Ȍ2 68ȀƢȀchronic care integration for endemic non-communicable diseases
ϐ Ǥ 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 Ǥ ǦǡǦ ϐ 4@49'#8&"A8'#847'*#$3).)^4'@&.":4'*#$#"*'&@4%'#84'.&9A'#4%:>'!4#$2 3.&+P4%*'*8&".5'34'*#$%#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'.&<' ȋζͷͷȌǡ ȋζͺͲ Ȍǡ Ǥ &6'34#$23.&+P4%*')9+."54'$AA%$@$#)&9'&6'$*#8:$'*7:-#&:*C'3%$57+$%5)$C' $95'87-1*)&9>
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PROTOCOL 4.5 Beta-Blocker Titration in Cardiomyopathy
Cardiomyopathy, diuretic adjustments made
HR ≤ 50 bpm OR SBP ≤ 80 bpm
YES NO
Decrease or do not start HR beta-blocker 50–60 bpm
NO
YES
At target dose of beta-blocker (Table 4.15) Maintain OR or do not start YES plan to increase beta-blocker ACE inhibitor OR decrease diuretic
NO
Increase Maintain Fluid beta-blocker or do not start overload YES NO dose beta-blocker (Table 4.9) (Table 4.15)
4.8.3.2 ACE Inhibitors LSU')98)3)#&%*'$%4'$'+.$**'&6':45)+$#)&9'#8$#'<&%P'&9'#84'P)5947*C'3.&&5' ǡ ǡ ϐ %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'-$#)49#*'<)#8'+$%2 5)&: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$9A4%&"*' Ǥ ηʹͲͲρȀȋηʹǤ͵Ȁ 5FX'*8&".5'9'34'-.$+45'&9'$9'LSU')98)3)#&%'"9.4**'-$**)":'.4@4.*' 70ȀƢȀchronic 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$9'g1'::,A>'
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4.8.3.3 Hydralazine and Isosorbide Dinitrate ,75%$.$^)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'$95')#' ϐ ǡ -$#)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)*&*&%2 3)54')9'+$%5)&:7&-$#87> chapter!4 | heart failureȀƢȀ71
PROTOCOL 4.6 ACE-Inhibitor Titration and Use of Hydralazine/Isosorbide in Cardiomyopathy
Cardiomyopathy, diuretic and beta-blocker adjustments made
Stop/do not start Able to check YES Pregnant NO ACE creatinine AND/OR inhibitors potassium?
YES NO
At ACE inhibitor Creatinine goal dose SBP ≥ 200 µmol/L NO ≤ 90 NO OR increasing AND/OR mmHg ≥ beta-blocker? K 5.5 mEq/L?
YES
Decrease or maintain YES YES ACE inhibitor NO
NO Maintain SBP ≥ 90 Decrease/ ACE inhibitor mmHg do not start dose ACE inhibitor
NO YES
Increase K ≥ 6.5 ACE inhibitor Start, mEq/L Wait to start or (Table 4.15) continue or decrease increase hydralazine hydralazine and isosorbide and dinitrate isosorbide Admit, treat (Table 4.15 ) dinitrate hyperkalemia (Table 4.15) (Section 6.5)
4.8.3.4 Spironolactone L*'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$9'J11'n:&.iF' ȋηʹǤ͵ȀȌǤǡ <)#8'+8%&9)+$..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> 72ȀƢȀchronic 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
Patient with cardiomyopathy, diuretic, beta-blocker and ACE inhibitor/hydralazine/isosorbide adjustments made
Woman Refer to between 15 and 49 YES family years planning
NO
Peripartum YES Aspirin CMP?
NO
Irregular Atrial YES heart rhythm fibrillation by ECG
NO NO YES
Alcohol Abstinence YES CMP? Start warfarin (see Chapter 5) NO Refer to infectious YES HIV? disease clinic NO
Class Digoxin III or IV YES symptoms (Table 4.16)
NO
Ascites OR ≤ ≤ K 3.5 mEq AND Cr 100 YES Spironolactone µmol/L AND SBP ≥ 90 (Table 4.15) chapter!4 | heart failureȀƢȀ73
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' ϐ )*'-%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)*' ζͳͲͲρȀǤKK'_4' %4*4%@4'5)A&E)9'6&%'-$#)49#*'<)#8'+.$**'???'&%'?\'84$%#'6$)."%4'*7:-#&:*>' ϐǡ 84.-'<)#8'%$#4'+&9#%&.>'
TABLE 4.16'.)*#*'%4+&::49545'5)A&E)9'5&*)9A>
TABLE 4.16 Digoxin Dosing
Starting dose Maximum dose
0.125 mg/day 0.25 mg/day
4.8.4.2 Aspirin _849'#84'84$%#'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".$#)&9'V*44'CHAPTER 5X>
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PROTOCOL 4.8 Management of Suspected or Confirmed Hypertensive Heart Disease
Suspected or confirmed hypertensive heart disease
Assess fluid status, adjust furosemide dose (Protocol 4.3, Tables 4.9 and 4.12)
Assess blood pressure and adjust hypertensive medications (Protocol 4.9)
Assess medication contraindications and side e!ects (Protocol 4.10)
Follow-up planning (Section 4.13, Table 4.23)
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4.9.3 Titration of Antihypertensives ?9'&%54%'#&'-%4@49#'<&%*49)9A'84$%#'6$)."%4'*7:-#&:*C'$9#)87-4%#492 ζͳ͵ͲȀͺͲǤ 76ȀƢȀchronic care integration for endemic non-communicable diseases
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TABLE 4.17 Antihypertensives for Hypertensive Heart Disease
First-line drug Initial dose Dose increase Maximum Side e"ects/cautions (ACE inhibitor) dose Lisinopril 5 mg 1x/day 5 mg 1x/day 20 mg 1x/day 1. Birth defects (contraindicated in pregnancy) Captopril 12.5 mg 3x/day 12.5 mg 3x/day 50 mg 3x/day 2. Chronic non-productive cough 3. High potassium 4. Worsened renal function Second-line drug Initial dose Dose increase Maximum Side e"ects/cautions (thiazide) dose Hydrochlorothiazide 12.5 mg 1x/day 12.5 mg 1x/day 25 mg 1x/day Lowers potassium
Third-line drug Initial dose Dose increase Maximum Side e"ects/cautions (CCB)* dose Amlodipine 5 mg 1x/day 5 mg 1x/day 10 mg 1x/day Lower-extremity swelling
Nifedipine 20 mg 2x/day 20 mg 2x/day 40 mg 2x/day (sustained release)
Fourth-line drug Initial dose Dose increase Maximum Side e"ects/cautions (beta-blocker) dose Atenolol 25 mg 1x/day 25 mg 1x/day 50 mg 1x/day 1. Bradycardia 2. Renally excreted 3. Decrease dose for renal failure Fifth-line drug Initial dose Dose increase Maximum Side e"ects/cautions (vasodilator) dose Hydralazine 25 mg 3x/day 25 mg 3x/day 50 mg 3x/day 1. Headache 2. Tachycardia 3. Lower-extremity swelling
* CCB = Calcium-channel blocker chapter!4 | heart failureȀƢȀ77
PROTOCOL 4.9 Antihypertensive Management in Hypertensive Heart Disease
Hypertensive heart disease diuretic dose adjustments already made
BP ≥ Add 2 drugs OR 160/100 YES increase 2 drug doses mmHg if already on 4 drugs
NO
BP ≥ 130/80 Add 1 drug OR ≤ 160/100 YES increase 1 drug dose mmHg if already on 4 drugs
NO
≥ BP 90/70 Maintain current ≤ YES 130/80 medications mmHg
NO
≤ Decrease current BP 90/70 YES mmHg medications 78ȀƢȀchronic care integration for endemic non-communicable diseases
PROTOCOL 4.10 Assessment of Medication Contraindications and Side E"ects in Management of Hypertensive Heart Disease
Suspected or confirmed hypertensive heart disease, diuretic and anti-hypertensive adjustments made
Pregnant, Cr ≥ 200 µmol/L Stop or do not start AND/OR YES captopril/lisinopril AND/OR K ≥ 5.5 mEq/L? spironolactone.
K ≥ 6.5 mEq/L
NO
YES NO
≤ Admit, treat HR 50 hyperkalemia bpm? (Section 6.5)
YES
Reduce, stop or do not start beta-blocker
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PROTOCOL 4.11 Management of Mitral Stenosis
Assess vital signs and clinical Mitral status. Treat and refer stenosis decompensated heart failure
Assess fluid status, adjust furosemide dose (Protocol 4.3, Tables 4.9 and 4.12)
HR ≥ 60 Start/increase bpm and atenolol if not YES SBP ≥ 90 contraindicated mmHg? (Table 4.10)
NO
Suspected Penicillin RHD and YES prophylaxis ≤ 40 years old? (Table 9.5)
NO
Refer to Female, age family planning between 15 YES and 49? (Section 3.5)
NO
Atrial Start warfarin if fibrillation feasable and not Aspirin 100 NO (on ECG) YES contraindicated, mg 1x/day AND/OR prior otherwise give aspirin stroke (Chapter 5)
Surgical Follow-up planning candidate? NO (Section 4.13, Table 4.23)
YES
Surgical planning (Chapter 5) 80ȀƢȀchronic care integration for endemic non-communicable diseases
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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 failureȀƢȀ81
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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$%#' ϐ ǯǤϐ 5)*4$*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&*)*> chapter!4 | heart failureȀƢȀ83
PROTOCOL 4.12 Valvular or Congenital Heart Disease Management (Excluding Mitral Stenosis)
Suspected or echocardiographically confirmed valvular or congenital heart disease. No evidence of mitral stenosis
Assess fluid status, adjust diuretic (Protocol 4.3, Tables 4.9 and 4.12)
Assess creatinine, potassium and need for ACE inhibitor (Protocol 4.13)
Assess other medication needs (Protocol 4.14)
Follow-up, surgical planning, consultation with a cardiologist
Surgical Follow-up planning candidate? NO (Section 4.13, Table 4.23)
YES
Surgical planning (Chapter 5)
4.11.1 Vital Sign Assessment L*'<)#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 ϐ &6'5)"%4#)+*>'Y44'SECTION 4.7C'TABLE 4.9C'$95'PROTOCOL 4.3> 84ȀƢȀchronic care integration for endemic non-communicable diseases
4.11.3 Titration of ACE Inhibitors ?9'-$#)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>' ǡ ϐ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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)
Valvular or congenital disease, diuretic adjustments made
Able to check creatinine AND/OR NO potassium?
YES
Pregnant, Stop/do not ≥ creatinine 200 SBP ≤ 100 start ACE YES NO µmol/L AND/OR mmHg inhibitors K ≥ 5.5 mEq/L?
NO
K ≥ 6.5 mEq/L
Maintain At YES ACE inhibitor YES ACE inhibitor dose goal dose
Treat for hyperkalemia NO (see Section 6.5)
Increase ACE inhibitor chapter!4 | heart failureȀƢȀ85
4.11.4 Other Medications 4.11.4.1 Spironolactone G$#)49#*'<)#8'5)*4$*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'-$#)49#*'<)#8' ȋηʹͲͲρȀηʹǤ͵ȀȌ 87-4%P$.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 Penicillin L*'54*+%)345')9'CHAPTER 9C'-49)+)..)9'-%&-87.$E)*'84.-*'*.&<'#84'-%&2 A%4**)&9'&6'%84":$#)+'@$.@".$%'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 ϐ Ǥ
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 86ȀƢȀchronic care integration for endemic non-communicable diseases
PROTOCOL 4.14 Other Medications for Valvular or Congenital Heart Disease Management (Excluding Mitral Stenosis)
Patient with congenital or valvular disease (excluding mitral stenosis) and diuretic, ACE-inhibitor adjustments made
Woman Refer to family between 15 YES planning and 49 years (Section 3.5)
NO
Suspected Penicillin RHD and YES prophylaxis age ≤ 40 (Table 9.5)
NO
Irregular heart rate YES Atrial fibrillation by ECG
YES NO NO
Protocol 4.9
Ascites AND K ≤ 3.5 mEq/L AND Start Cr ≤ 100 µmol/L YES spironolactone AND SBP ≥ 90 (Table 4.15) mmHg
4.11.5 Cardiac Surgery Evaluation ϐ 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' ϐ ǤǦ +&:-49*$#45':$7'34'+$95)5$#4*'6&%'*"%A)+$.')9#4%@49#)&9'346&%4'#847' chapter!4 | heart failureȀƢȀ87
34A)9'#&'54+&:-49*$#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
ϐ Ǧ 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:$' ǡϐ 4:-)%)+'#"34%+".&*)*'#%4$#:49#>'
G$#)49#*'<)#8'$*+)#4*'+$"*45'37'.)@4%'6$)."%4'&%'%49$.'6$)."%4'+$9'%4*4:3.4' ǦǤ ϐ 5)*#)9A")*8'34#<449'#84*4'-$#)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' 88ȀƢȀchronic 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'$95'FIGURE 4.8X>
TABLE 4.21 Causes of Right-Sided Heart Failure
Cause Notes
Left-sided heart failure Left-sided heart failure is the most common cause of right-sided heart failure. Some common causes include cardiomyopathy, mitral stenosis, and mitral regurgitation Tricuspid valve abnormalities Tricuspid valve stenosis, tricuspid regurgitation, congenital heart disease
Pulmonary disease Pulmonary TB, severe COPD
Pulmonary hypertension HIV, congenital heart disease (commonly VSD, ASD), other
Constrictive pericarditis Most commonly caused by TB
Endomyocardial fibrosis Cause unknown
Ǧ ϐ )549#)67)9A'#8&*4'-$#)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' ȋ ϐȌ <)..'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$)."%4> chapter!4 | heart failureȀƢȀ89
PROTOCOL 4.15 Management of Isolated Right-Sided Heart Failure
Suspected or echocardiographically confirmed isolated right sided heart failure
Assess fluid status, adjust diuretic (Protocol 4.16)
Assess for tuberculosis pericarditis (Protocol 4.17)
Assess creatinine, potassium and need for ACE inhibitor (Protocol 4.18)
Assess other medication needs (Protocol 4.19)
Follow-up and consultation with a cardiologist to confirm diagnosis
Surgical Follow-up planning candidate? NO (Section 4.13, Table 4.23)
YES
Surgical planning (Chapter 5)
4.12.1 Vital Sign Assessment L*'<)#8'$..'#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*)*> 90ȀƢȀchronic care integration for endemic non-communicable diseases
4.12.2 Fluid Status Assessment H84'94E#'*#4-')9'#84':$9$A4:49#'&6'%)A8#2*)545'84$%#'6$)."%4')*'4@$."$2 ϐ Ǥ -%&6&"95'.4A'454:$'$95'$*+)#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':$)9'#&&.'6&%'+&92 ǯϐǤSECTION 4.7.2>
Y-)%&9&.$+#&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*)*':$7'34'-4%6&%:45'V*44'SECTION 4.12.4X>
PROTOCOL 4.16 Fluid Status Management in Right-Sided Heart Failure
Suspected or confirmed isolated right-heart failure
Perform volume assessment (definitions of fluid status di!erent than for other types of heart failure)
Hypo- Hyper- volemia (1) volemia
Euvolemia (2) Moderate Severe Stop all (3) (4) diuretics, consider giving fluids
IV diuresis, ≤ On 80 mg paracentesis, furosemide hospitalize 2x/day? NO YES
Maintatin furosemide Increase dose, consider adding furosemide sprionolactone and dose ACE inhibitor (Section 4.7.2) (Protocol 4.18)
(1) Hypovolemia: Rising creatinine, low blood pressure; may still have significant edema or ascites (2) Euvolemia: Comfortable, able to perform daily activities (3) Hypervolemia, Moderate: Increasing ascites or edema, uncomfortable but able to do basic activities (4) Hypervolemia, Severe: Rapid breathing, unable to walk chapter!4 | heart failureȀƢȀ91
4.12.3 Pericardial Disease ()*4$*4*'&6'#84'-4%)+$%5)":'6$..')9#&'#<&':$)9'+$#4A&%)4*W'V/X'-4%)+$%2 5)$.'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' ǡϐǤ
4.12.3.1 Pericardial E#usions ϐ Ǥ2 ȋͳ Ȍ ϐ $..'6&%:*'&6'84$%#'6$)."%4>',&<4@4%C'.$%A4'-4%)+$%5)$.'466"*)&9*'<)#8&"#' ϐ ȋȌǡ +$9+4%*C'&%'@)%$.')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' ϐȋFIGURE 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$54>' ϐ V-4%)+$%5)&+49#4*)*X>
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4.12.3.3 Diagnosis and Treatment of Tuberculosis Pericarditis G%&:-#')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' 92ȀƢȀchronic care integration for endemic non-communicable diseases
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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 40 mg twice per day 4 weeks, followed by (example for a 50–55 kg 20 mg twice per daily 4 weeks, followed by patient) 10 mg twice per day 2 weeks, followed by
5 mg once daily 1 week chapter!4 | heart failureȀƢȀ93
PROTOCOL 4.17 Diagnosis and Treatment of Tuberculosis Pericarditis
Suspected constrictive pericardial disease, diuretic adjustments made
Obtain Sputum smears, CXR or history CXR, YES start empiric TB HIV test suggestive of treatment TB?
NO
Very large right Do not start ventricle YES treatment (Figure 4.8) for TB
NO
Sputum smears, start empiric TB Treatment
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' ȋηʹͲͲρȀηʹǤ͵Ȁ 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>
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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)*> 94ȀƢȀchronic care integration for endemic non-communicable diseases
PROTOCOL 4.18 ACE-Inhibitor and Spironolactone Titration and Paracentesis for Isolated Right-Sided Heart Failure
Isolated right-sided heart failure, furosemide adjustments made
Able to check creatinine and/ NO or potassium?
YES
Pregnant, Stop/do not ≥ Cr 200 µmol/L SBP ≤ 100 start ACE YES NO AND/OR mmHg inhibitors K ≥ 5.5 mEq/L
YES NO
K ≥ 6.5 Maintain or decrease mEq/L ACE inhibitor AND/OR spironolactone ACE inhibitor YES at goal dose YES
Treat for hyperkalemia NO (see Section 6.5) Maintain ACE inhibitor at current dose, add spironolactone Increase (Table 4.15) ACE inhibitor
4.12.5 Other Medication Needs G$#)49#*'<)#8')*&.$#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$9+7' Ǥ ϐ *8&".5'34'%$#42+&9#%&..45'$95'$9#)+&$A".$#45> chapter!4 | heart failureȀƢȀ95
PROTOCOL 4.19 Other Medication Needs in Isolated Right-Sided Heart Failure
Patient with isolated right-sided heart failure; diuretic, ACE inhibitor adjustments made
Woman Refer to family between 15 YES planning and 49 years (see Section 3.5)
NO
Irregular YES Atrial fibrillation heart rate by ECG
YES NO NO
Protocol 4.9
Refer to ID HIV YES clinic to start ARVs
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TABLE 4.23 Clinic Follow-Up Schedule for Heart Failure Patients
Class I or Class II heart Class III or Class IV symptoms, new renal failure, failure, euvolemic hypervolemic or any other clinical concern
Medication change Return in 2 weeks–1 month Return in 1–2 weeks
No medication change Return in 1–2 months Return in 2 weeks–1 month
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4.16 Role of Electrocardiography in Rural Rwanda U.4+#%&+$%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 failureȀƢȀ97
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4.16.1 Atrial Fibrillation Diagnosis and Management ϐ +.)9)+)$9*'&3#$)9'$9'UST'&9'$97'-$#)49#'<)#8'$9')%%4A".$%'-".*4'&%'$'@4%7' ȋηͳʹͲȌǤ #84'UST')9'#84'+.)9)+'&%'$++&:-$97'#84'-$#)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'$%4'O"4*#)&9*>'H84'P47'UST' ϐϐȋͳȌ Ǣ VJX')%%4A".$%.7'*-$+45's;Y'<$@4*'V*44'FIGURE 4.10X> A
A 98ȀƢȀchronic care integration for endemic non-communicable diseases
º FIGURE 4.10 ECG of Normal Rhythm (top) and Atrial Fibrillation (bottom) P waves, regular (normal rhythm)
P waves
no P waves, irregular (atrial fibrillation)
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ϐǦ $*7:-#&:$#)+'$%4'*#)..'$#'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"#)+'?`;> chapter!4 | heart failureȀƢȀ99
PROTOCOL 4.20 Diagnosis and Management of Atrial Fibrillation
Patient with tachycardia (≥ 120 bpm) AND/OR irregular heart beat
Obtain 12-lead ECG to confirm atrial fibrillation
Atrial fibrillation Likely sinus rhythm. If tachycardic, look (absence of P waves NO for underlying cause (fever, pain, etc.) and irregularly spaced and consider hospital admission QRS waves)
Lower heart rate with YES beta-blocker and admit to hospital YES
HR ≥ 120 YES SBP ≥ 100 bpm mmHg NO Admit to hospital, NO load with digoxin (Table 4.18). If unstable, consider Known cardioversion Initiate structural YES anticoagulation heart (see ) disease Chapter 5
NO
Start on aspirin 100 mg daily, obtain an echocardiogram
4.17 Cardioversion H84':$)9')95)+$#)&9'6&%'+$%5)&@4%*)&9')*'+$%5)&A49)+'*8&+P')9'#84'*4##)9A' ϐǤ Ǥ 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*)+)$9> 100ȀƢȀchronic care integration for endemic non-communicable diseases
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PROTOCOL 4.21 Palpitations
Murmur, No P edema, Treat as atrial Patient with Palpitations ECG waves or orthopnea or NO YES YES YES fibrillation (see palpitations currently? available? irregular exertional Protocol 4.20) dyspnea? rhythm?
NO NO
NO YES Work up ≥ Pulse 100 bpm or infection, pauses or extra YES Fever? YES consider beats by palpation? Investigate as antibiotics suspected heart failure (see Protocol 4.1) NO NO
Signs of Look for and YES treat underlying Reassure dehydration? cause patient, stop any cardiac medications. NO Refer back to primary care
Atenolol 12.5 mg 1x per day or propranolol 10 mg 3x per day
Goiter? NO Refer for ECG
YES
Check thyroid function tests and refer for ECG chapter!4 | heart failureȀƢȀ101
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G$#)49#*'$+#)@4.7'57)9A'&6'84$%#'6$)."%4'*&:4#):4*'8$@4'8&"%*'&%'5$7*'&6' 57*-94$'$95'T%'*7:-#&:*'$95'%4O")%4'+$%46".'#)#%$#)&9'&6':&%-8)94' A)@49'$%&"952#842+.&+P'#&'$**"%4'+&:6&%#>'?9'*&:4'+$*4*C'84$.#8'+49#4%' 9"%*4*'$95'+&::"9)#7'84$.#8'<&%P4%*':$7'34'$3.4'#&'-%&@)54'#8)*'+$%4' )9'-$#)49#*='8&:4*'&9+4'$--%&-%)$#4'-%4*+%)-#)&9*'8$@4'3449'<%)##49' 37'$'5)*#%)+#2.4@4.'-87*)+)$9>'G$#)49#*'<)#8'*4@4%4'&%'+&:-.4E'*7:-#&:*' :$7'%4O")%4'4952&62.)64'+$%4'$#'#84'84$.#8'+49#4%'&%'5)*#%)+#'.4@4.>
G$#)49#*'<)#8'84$%#'6$)."%4'$.*&':$7'8$@4'*"5549'+$%5)$+'54$#8>'?#':$7' 34'$--%&-%)$#4'#&')96&%:'*&:4'6$:).)4*'$95'-$#)49#*'&6'#8)*'-&**)3).)#7>' 102ȀƢȀchronic care integration for endemic non-communicable diseases
S$%4'*8&".5'34'#$P49'<8494@4%'A)@)9A'3$5'94<*'#&':)9):)^4'4:)&9$.' 5)*#%4**'6&%'#84'-$#)49#'$95'6$:).7>'H8)*'+$9'34'5&94')9'*4@4%$.'<$7*W'' /X'37'*"AA4*#)9A'#8$#'*"--&%#'-4%*&9*'*"+8'$*'6$:).7':4:34%*'&%'6%)495*' 34'-%4*49#'<849'3$5'94<*'<)..'34'5)*+"**45h'JX'37'#$P)9A'#84'#):4'#&'*)#' 5&<9'<)#8'#84'-$#)49#'&%'6$:).7'$95'A)@4'#84:'$'+8$9+4'#&'$3*&%3'#84' Ǣ͵Ȍϐǯǯ 5)*4$*4'$95'A49#.7'+&%%4+#)9A':)*+&9+4-#)&9*h'KX'37'34)9A'-%4-$%45'6&%' *#%&9A'%4$+#)&9*C'*"+8'$*'$9A4%'&%'A%)46h'0X'37'&664%)9A'#&'*44'#84'-$#)49#' &%'6$:).7'$A$)9'*&&9'#&'$9*<4%'O"4*#)&9*'$95'-%&@)54'4:)&9$.'*"--&%#> chapter!4 | heart failureȀƢȀ103
Chapter 4!References
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5.1 History of Cardiac Surgery in Rwanda H84'8)*#&%7'&6'+$%5)$+'*"%A4%7')9';<$95$'-%)&%'#&'/ddK')*'9'<4..' P9&<9>'!4#<449'/dd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`&@4:34%' J11]'$95'[43%"$%7'J1/1> 108ȀƢȀchronic care integration for endemic non-communicable diseases
FIGURE 5.1 Indication for Cardiac Surgery between Nov. 2007 and Feb. 2010 (%) 3%
43% 54%
Congenital Open rheumatic Other
FIGURE 5.2 Source of Cardiac Surgery in Rwanda between Nov. 2007 and Feb. 2010 (n)
9
29
132
Visting cardiac surgical team External referral Closed cardiac surgery by local thoracic surgeon chapter!5 | cardiac surgeryȀƢȀ109
5.1.1 Out-of-Country Referral to External Cardiac Surgical Centers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5.1.1.1 Philanthropic Centers R$97'+49#4%*')9'#84'a9)#45'Y#$#4*'$95'U"%&-4'<)..'&++$*)&9$..7'-4%6&%:' +$%5)$+'*"%A4%7'&9'$'-8).$9#8%&-)+'3$*)*>'H84*4'+49#4%*':"*#'%$)*4'6"95*' #&'+&@4%'#84'%4$.'+&*#*'&6'#84*4'-%&+45"%4*'$95'&6#49'.&&P'#&'%4A)&9$.' 5&9&%*'6&%'*"--&%#>',&<4@4%C'#84'+&*#'&6'+$%4'$#'#84*4'+49#4%*')*'8)A8C' Ǥǡϐ 6%&:'L6%)+$'&6#49'%$)*4'$<$%494**'$95'.4$5'#&')9+%4$*45'49A$A4:49#' 6%&:')9*#)#"#)&9*')9'<4$.#87'+&"9#%)4*>'H84*4'4664+#*'8$@4'@$."4'$3&@4' $95'347&95'#84'@$."4'&6'.)642*$@)9A'*"%A4%7')#*4.6>'?9'#84'.&9A4%'%"9C'8&<2 4@4%C'<4'644.'#8$#':&947'%$)*45'6&%'-8).$9#8%&-)+'+$%5)$+'*"%A4%7'+&".5' 34'34##4%'5)%4+#45'#&<$%5'*"--&%#)9A'.&<4%2+&*#'+$%4'#8%&"A8'%4A)&9$.' +49#4%*')9':)55.42)9+&:4'+&"9#%)4*'$95')9'L6%)+$')#*4.6>'
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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 ϐ Ǥǡ /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&*-)#$.'.4@4.>'H84'6&..&<)9A' ϐǦǤ 112ȀƢȀchronic care integration for endemic non-communicable diseases
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TABLE 5.1'*8&<*'#84'#7-)+$.'4@$."$#)&9*'%4O"4*#45'37'+$%5)$+'*"%A)+$.' #4$:*'-%)&%'#&'*"%A4%7> chapter!5 | cardiac surgeryȀƢȀ113
TABLE 5.1 Typical Preoperative Evaluation for Cardiac Surgery
History
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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 116ȀƢȀchronic care integration for endemic non-communicable diseases
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5.3.4 Bioprosthetic Valves !)&-%&*#84#)+'@$.@4*'$%4':$54'6%&:'.)@)9A'#)**"4'V6%&:'$'+&
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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 Ƣǽ!'(+"1#- Ƣǽ,#-ǽ Ƣǽ6.,#-ǽ.$ǽ!'(+"ƽ # 1(-%ǽ %#ǽ6'.ǽ"#2(1#ǽ Ƣǽ6.,#-ǽ.$ǽ!'(+"ƽ # 1(-%ǽ %#ǽ6'.ǽ".ǽ-.3ǽ future pregnancies desire more children Ƣǽ6.,#-ǽ-.3ǽ.$ǽ!'(+"ƽ # 1(-%ǽ %#
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TABLE 5.4 Empiric Antibiotic Treatments for Endocarditis
Antibiotic Indication Adult dose Pediatrics dose E"ect on warfarin
Vancomycin Empiric endocarditis therapy, 1 gm 2x/d 10 mg/kg 4x/d No e#ect methicillin-resistant Staphylococcus aureus, Staphylococcus epidermidis, enterococcus OR (Combination therapy with cloxacillin + ceftriaxone or penicillin G)
Cloxacillin Empiric endocarditis therapy, 2 gm daily IV 50 mg/kg every No e#ect methicillin-sensitive Staphylococcus 6 hours IV aureus, empiric treatment of cellulitis in patients with prosthetic heart valves Ceftriaxone Empiric endocarditis therapy, 2 gm daily IV 100 mg/kg/d IV Decreases Streptococcus viridans, empiric or IM or IM (maximum warfarin e#ect treatment of urinary tract infection, 2 gm) pneumonia in patients with prosthetic heart valve Penicillin G Empiric endocarditis therapy, 4.5 million 50,000 U/kg IV No e#ect Streptococcus viridans units IV 4x/d 4x/d
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PROTOCOL 5.1 Management of Fever in Patients with Prosthetic Heart Valves
1. Heart failure 1. Hospitalize at district hospital Patient with OR 2. Stabilize blood pressure with fluids ≤ prosthetic 2. BP 80/40 mmHg 3. Draw two sets of blood cultures OR YES valve and fever 4. Start empiric antibiotics for endocarditis (Table 5.4) (T ≥ 38° C or 3. Other signs of sepsis 100.4° F) or endocarditis 5. Transfer as quickly as possible to referral hospital (e.g., new murmur) for admission, blood culture, echocardiography, and specific antibiotic therapy
NO
1. History and physical examination Followed by laboratory evaluation as needed: 1. Urinalysis 2. Peripheral blood smear for malaria 3. Chest x-ray NO
Clear source of fever?
YES NO
1. Hospitalize at district level 2. Treat infection empirically Continue management with careful attention to: Improvement within 48 hours 1. Warfarin management (if relevant) 2. In-hospital risks such as IV-line and urinary catheter infections 3. Venous thromboembolism
YES NO
No fever within 14 days from admission
YES
Weekly follow-up at NCD clinic for 1 month
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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 50 mg/kg every 6 No e#ect divided into 3 doses hours IV 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 No e#ect hours IV Gentamycin 2 weeks 3 mg/kg/day IV or IM 50 mg/kg every 6 No e#ect divided into 3 doses hours IV 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 Decreases warfarin IM (maximum 2 gm) e#ect Penicillin G 6 weeks 4.5 million units IV 50,000 U/kg IV 4x/d No e#ect 4x/d
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5.6 Penicillin Prophylaxis for Patients with Surgically Corrected Rheumatic Valvular Disease G$#)49#*'<)#8'%84":$#)+'@$.@".$%'5)*4$*4'*8&".5'34'#%4$#45'<)#8'-49)+).2 .)9'#&'-%4@49#'6"%#84%'*#%4-#&+&++$.'#8%&$#')964+#)&9*'$95'%4+"%%49#' %84":$#)+'64@4%>'?9'-$#)49#*'<8&'8$@4'*"%A)+$..7'%4-$)%45'&%'%4-.$+45' @$.@4*'6&%'%84":$#)+'84$%#'5)*4$*4C'-49)+)..)9'-%&-87.$E)*'*8&".5'34' +&9#)9"45>';4-4$#')964+#)&9*'+$9'%4*".#')9'5$:$A4'#&'T%'84$%#'@$.@4*C' <8)+8':$7'$.*&'%4O")%4'*"%A4%7>'H84*4'&"#+&:4*'+$9'34'$@&)545'<)#8' #84'$--%&-%)$#4'"*4'&6'-49)+)..)9>'Y44'TABLE 9.5'6&%'54#$).*'&9'#84'"*4'&6' -49)+)..)9'6&%'-%&-87.$E)*>
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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 surgeryȀƢȀ125
$9#)+&$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$%)9>
TABLE 5.6 Common Drug Interactions with Warfarin
Drug E"ect on INR
Co-trimoxazole Increase
Metronidazole Increase
Ciprofloxacin Increase
Cimetidine Increase
Rifampin Decrease
Antiretroviral drugs Increase or decrease
Alcohol Increase or decrease
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S&::&9')95)+$#)&9*'6&%'$9#)+&$A".$#)&9')9'&"%'+.)9)+*'$95'5)*#%)+#'8&*-)2 Ȃ ǡϐǡ2 *)*C'.46#'@49#%)+".$%'#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> 126ȀƢȀchronic care integration for endemic non-communicable diseases
TABLE 5.7 Anticoagulation Agents and Indications
Indications Warfarin or aspirin? Heparin Goal INR Duration of bridge? 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 Yes 2.5–3.0 Lifelong first 3 months, then aspirin 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".$#)&9' ϐǤ
5.8.1 Contraindications to Warfarin Therapy !46&%4'*#$%#)9A'<$%6$%)9'#84%$-7C'-$#)49#*'*8&".5'34'$**4**45'6&%'%4.$2 #)@4'+&9#%$)95)+$#)&9*'#&'<$%6$%)9'#84%$-7>
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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*>' 2.5 mg/day ϐ 6&%'#84)%'%)*P'&6'*#%&P4'&%'T%'4:3&.)+'4@49#*>'G$#)49#*'$#'.&<'%)*P'&6' ϐǤ 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
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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/d Child: 250 units/kg 2x/d
ǡ ϐǡ <$%6$%)9'&9'$9'&"#-$#)49#'3$*)*'<)#8&"#'$'84-$%)9'3%)5A4>'PROTOCOL 5.2' &"#.)94*'#84'*#4-*')9@&.@45')9')9)#)$#)9A'<$%6$%)9'#84%$-7>
PROTOCOL 5.2 Initiating Warfarin Therapy
1. Admit to district hospital Patient with Requires heparin 2. Start warfarin (Table 5.8) indication for bridge because high risk YES warfarin of embolic events? 3. Start a medication to bridge (Table 5.9) the patient (Table 5.9)
NO
Reconsider indications for Patient YES warfarin. Consider aspirin pregnant? as an alternative
NO
Palpable liver on Check INR prior YES to initiating Elevated exam or known INR? liver failure? warfarin therapy
NO YES
If INR ≥ goal INR do not start warfarin Start warfarin therapy: If INR ≤ goal INR, start warfarin at half Adults: 2.5 mg/day normal dose (Table 5.10) Chidren 5–40 kg: 1 mg/day
Assign community health worker
Follow-up in one week at the district hospital chapter!5 | cardiac surgeryȀƢȀ129
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TABLE 5.10'&"#.)94*'A494%$.'A")54.)94*'6&%'<$%6$%)9'#)#%$#)&9>'L*'9-C' 8&<4@4%C')95)@)5"$.'-$#)49#*'<)..'%4*-&95'5)664%49#.7'#&'<$%6$%)9>'_849' )9'5&"3#C'#84'#%4$#)9A'+.)9)+)$9'*8&".5'+&9*".#'$':&%4'*49)&%'+.)9)+)$9>' ?9'&"%'+.)9)+*C'&"%'-%&@)54%*'$%4'49+&"%$A45'#&'+$..'&%'4:$).'&94'&6'#84' +$%5)&.&A)*#*')9'#84'+$-)#&.'6&%'A")5$9+4> 130ȀƢȀchronic 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 days Decrease warfarin dose by 1 mg
Above goal (INR elevated by less than 2.0) Evaluate for changes in medications or diet Decrease warfarin dose by 0.5–1 mg At goal Continue current warfarin dose
Below goal Evaluate for changes in medications or diet Assess for nonadherence Increase 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) therapy Assess for nonadherence and discuss with the patient’s community health worker
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PROTOCOL 5.3 Titrating Warfarin Therapy
1. Hold warfarin Patient on INR ≥ 5 YES 2. Admit to district hospital warfarin 3. Consider reasons for high INR and address 4. Recheck INR in 2 days
NO
INR ≥ 1 Currently 1. Continue to hold warfarin above goal, YES hospitalized YES but ≤ 5 for high INR 2. Recheck INR in 2 days
NO 1. Decrease warfarin by 10%–20% 2. Recheck INR in 3 days
NO NO INR previously at goal YES 1. Recheck INR in 2 weeks for ≥ 1 month
1. Continue warfarin INR at goal Currently 2. Observe for 1 day, recheck INR OR YES hospitalized YES 3. If INR still near goal, discharge ≤ 1 above for low INR goal 4. Recheck INR in one week
NO
Reason for 1. Restart warfarin at previous dose Currently high INR identified 2. Observe for 1 day, recheck INR hospitalized for YES and resolved (e.g., YES high INR 3. If INR still near goal, discharge overdose, acute 4. Recheck INR in one week illness)
NO NO
1. Restart warfarin at lower dose (10%–20% lower than original dose) 2. Observe for 1 day, recheck INR 3. If INR still near goal, discharge 4. Recheck INR in one week
INR lower Patient 1. Increase warfarin by 10%–20% YES taking YES than goal but 2. Recheck INR in 1 week ≥ 1.5 warfain?
NO
1. Address reason for non-adherence NO 2. Restart warfarin at previous dose 3. Recheck INR in 1 week
1. Hospitalize Patient 2. Start enoxaprin OR, if enoxaparin 1. Increase warfarin by 10%–20% INR ≤ 1.5 YES taking YES not available start heparin SC warfain? 2. Recheck INR in 3 days (Table 5.9)
NO
1. Address reason for non-adherence 2. Restart warfarin at previous dose 3. Recheck INR in 3 days
5.10 Drug Supply and Patient Monitoring ?9';<$95$C'$*-)%)9')*'#84'&9.7'$9#)+&$A".$9#'<)54.7'$@$).$3.4'$#'#84' 5)*#%)+#'8&*-)#$.'.4@4.>'G?,2*"--&%#45'5)*#%)+#'8&*-)#$.*'-%&+"%4'$'.):)#45' *"--.7'&6'<$%6$%)9'$95'84-$%)9C'$95'&"%'5)*#%)+#'`S('+.)9)+*'$..'8$@4' -&)9#2&62+$%4'?`;':$+8)94*'#&':&9)#&%'-$#)49#*>'L..'-$#)49#*'&9'<$%6$%)9' %4+4)@4'5)%4+#.7'&3*4%@45'#84%$-7'$5:)9)*#4%45'37'$'+&::"9)#7'84$.#8' 132ȀƢȀchronic care integration for endemic non-communicable diseases
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Chapter 5!References
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TABLE 6.1 Causes of End-Stage Renal Disease in Sub-Saharan Africa and the U.S.
Glomerulonephritis Hypertension Diabetes Other or unknown Average (Nigeria 54% 27.4% 11.9% 6.7% and Senegal)1
USA3 15.4% 24.2% 37.3% 22.9% 136ȀƢȀchronic care integration for endemic non-communicable diseases
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6.2.3 HIV ,?\')*'#8&"A8#'#&'+$"*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 diseaseȀƢȀ137
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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
ǡ ϐ %4*".#'&9'$#'.4$*#'J'&"#'&6'B'#4*#*>'G%)9"%)$'&6#49'$++&:-$9)4*'"%)9$%7' #%$+#')964+#)&9*C'3"#'$'-&*)#)@4'#4*#'+$9'$.*&'34'+$"*45'37'-4%)94$.'+4..*' +&9#$:)9$#)9A'#84'*-4+):49>'?9'-%$+#)+4C'<4'%4+&::495'#8$#'$97'"%)94' <)#8'4-)#84.)$.'+4..*C'.4"P&+7#4*C'&%'9)#%)#4*'9'34'%4A$%545'$*'-&*)#)@4' 6&%'-%)9"%)$>'?6'#84%4'$%4':$97'4-)#84.)$.'+4..*C'#84'#4*#'*8&".5'34' 138ȀƢȀchronic care integration for endemic non-communicable diseases
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TABLE 6.3'&"#.)94*'#84'5)664%49#'*#$A4*'&6'+8%&9)+'P)5947'5)*4$*4'VSM(X>' ϐǡ SM(2UG?'4O"$#)&9>'SM('*#$A4*'/'$95'J'%464%'#&'-$#)49#*'<)#8'9&%:$.'A.&2 ϐȋηͲȀȌǡ2 ȋ ȌǤ͵ϐ P)5947'):-$)%: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:-#&:*> chapter!6 | chronic kidney diseaseȀƢȀ139
TABLE 6.3 Stages of Chronic Kidney Disease
Degree of dysfunction Glomerular filtration rate
CKD 1 and 2 Proteinuria alone η 60 ml/min/1.73m2
CKD 3 Moderate dysfunction 30–59 ml/min/1.73m2
CKD 4 and 5 Severe dysfunction ζ29 ml/min/1.73m2
6.4 Initial Evaluation and Management of Chronic Kidney Disease (CKD) PROTOCOL 6.1'$95'PROTOCOL 6.2'&"#.)94'&"%'$--%&$+8'#&'#84')9)#)$.' 4@$."$#)&9'&6'P)5947'5)*4$*4'3$*45'&9'#84'*4@4%)#7'&6'57*6"9+#)&9>'R&*#' )95)@)5"$.*'$%4'6&"95'#&'8$@4'SM('/'&%'J'#8%&"A8'5)-*#)+P'*+%449)9A' $6#4%'#847'$%4'$.%4$57'5)$A9&*45'<)#8',?\C'5)$34#4*C'&%'87-4%#49*)&9>' H84*4'-$#)49#*'$%4'%464%%45'#&'5)*#%)+#28&*-)#$.'`S('+.)9)+*'#&'8$@4'#84)%' +%4$#)9)94'4@$."$#45C'*)9+4'+%4$#)9)94'#4*#)9A')*'9'"*"$..7'$@$).$3.4'$#' Ǥ ϐ 3%4$#8)9AC'-$#)49#*'*8&".5'34'8&*-)#$.)^45'6&%'6"%#84%'4@$."$#)&9'$95' #%4$#:49#>'L..'-$#)49#*'*8&".5'8$@4'#84'6&..&<)9A'#4*#*'&9'#84)%')9)#)$.' @)*)#'#&'#84'`S('+.)9)+W'3.&&5'-%4**"%4C'"%)94'5)-*#)+PC',?\'#4*#C'4.4+#%&2 .7#4'-$94.C'+%4$#)9)94C'A."+&*4C'$95'84:&A.&3)9>
PROTOCOL 6.1 Initial Evaluation of Chronic Kidney Disease Stage 1 or 2
Referred to NCD clinic for suspected or confirmed CKD ANY? 1. Signs of urinary Check blood pressure, urine dipstick, HIV and obstruction (difficulty urinating Refer to district hospital electrolyte panel including and abdominal pain or distention)? YES for admission creatinine, glucose, and hemoglobin 2. Potassium ≥ 6.5 mEq/L? 3. Di!culty breathing?
NO 1. Obtain serum albumin 2. If CKD 1-3, start low-dose ACE inhibitor unless Obtain random urine protein contraindications ≥ 3+ proteinuria YES ratio ≥ 3 YES to creatinine ratio (see Table 8.5) 3. Refer for evaluation for nephrotic syndrome by a nephrologist, internist, or pediatrician
NO NO
1. If patients already followed in continuity clinic, (e.g., for HTN, CKD 1 or 2 DM or HIV) continue management in that clinic (at health- (nl GFR, 2+ center level) YES HIV NO proteinuria, no 2. Start ACE inhibitor unless contraindication (see Table 8.5) infection) 3. Blood pressure goal ≤ 120/80 mmHg (see Table 8.5) 4. Avoid NSAIDs, other nephrotoxins 5. Return to NCD clinic once per year to check creatinine YES
Consider early ARV initiation 140ȀƢȀchronic care integration for endemic non-communicable diseases
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ͳʹ ϐǡ2 .&<45'$#'#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&$.'3.&&5'-%4**"%4' ͳ͵ͲȀͺͲ ǤǦǦϐ V`YL?(*XC'*"+8'$*')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' ϐ ȋ ' $*'84$%#'6$)."%4X> chapter!6 | chronic kidney diseaseȀƢȀ141
PROTOCOL 6.2 Initial Evaluation of Chronic Kidney Disease Stage 3, 4, and 5
Referred to NCD clinic for suspected or confirmed CKD
ANY? 1. Signs of urinary Check blood pressure, urine obstruction (difficulty urinating Refer to district hospital dipstick, HIV and electrolyte and abdominal pain or distention)? YES for admission panel including creatinine and 2. Potassium ≥ 6.5 mEq/L? glucose and hemoglobin 3. Di!culty breathing?
NO
CKD 3, 4, or 5 (GFR ≤ 59)
Fill out intake form for edematous conditions, including screening questions for heart failure, TB, and a basic echocardiogram, and kidney ultrasound
Potentially reversible? Meets all criteria: Refer to a nephrologist, 1. No heart failure internist, or pediatrician for YES 2. No ultrasound signs of irreversible evaluation and possible kidney disease (see Table 6.3) specific therapy
NO
1. Start ACE unless contraindication Control of Return in NCD CKD 3 2. Start FeSO4 200 mg HIV, DM, underlying clinic in 3-6 YES (GFR 30–59) 3x/day x 30 days if Hb or heart YES disease process months to ≤ 10 g/dL failure? (e.g., glucose recheck 3. Goal BP ≤ 130/80 control, ARVs) creatinine mmHg (see Table 8.5)
NO
Refer to a 1. Control BP nephrologist, (goal ≤ 130/80) internist, or 2. Consider Assess and address CKD 4 or 5 Option for renal pediatrician YES furosemide symptoms YES (GFR ≤ 29) transplant? for evaluation 3. Avoid ACE (see Protocol 6.3) inhibitors and possible (see Table 8.6) specific therapy
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FIGURE 6.1 Normal Kidney Anatomy on Ultrasound (Arrowheads show the medullary pyramids, and star shows the outer cortex) chapter!6 | chronic kidney diseaseȀƢȀ143
FIGURE 6.2 Ultrasound in Chronic Kidney Disease: Loss of Di"erentiation between Cortex and Medulla
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TABLE 6.4 Ultrasound Findings Specific for Severe, Irreversible Kidney Disease
1. Echogenic cortex (more than liver), plus a combined length ζ 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> 144ȀƢȀchronic care integration for endemic non-communicable diseases
FIGURE 6.3 Hydronephrosis on Ultrasound
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PROTOCOL 6.3 Outpatient Management of Mild Hyperkalemia
Taking ACE inhibitors, Stop these medications K 5–6 mEq/L YES spironolactone or YES and return to NCD clinic K supplement? in two weeks
NO
1. Start or increase furosemide Estimated GFR dose (starting dose 20 mg orally 1 time per day) unless ≤ 59 YES contraindication (CKD 3, 4, or 5) 2. Return to NCD clinic in two weeks
NO
Repeat K test NO
False positive due to YES Continue usual follow-up hemolysis 146ȀƢȀchronic care integration for endemic non-communicable diseases
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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 Depression Assess for depression and treat if found. drowsiness Fluid overload Diurese for fluid overload, if needed. 86% Anemia, poor nutrition, other organ failure, uremia, insomnia Itch Dry skin Emollients for dry skin. 84% Secondary hyperparathyroidism Antihistamine such as diphenhydramine (can worsen Hyperphosphatemia fatigue and delirium). Anemia Steroid. Opioids Dyspnea (the Pulmonary edema If comfort and quality of life are the only goals of most distressing Pleural e#usion care, not preservation of renal function, diurese for symptom) symptomatic pulmonary or peripheral edema. Metabolic acidosis 80% Opioid relieves dyspnea of any cause. Renal dosing Anemia for morphine (see APPENDIX A). Aspiration Comorbid CHF, COPD, or other lung pathology Delirium (agitated Metabolic derangements Reduce or eliminate culprit medications, if possible. or hypoactive) Hypoxia/hypercapnia Haloperidol. 76% Medications Pain Bone pain due to 2˚ Avoid NSAIDS due to nephrotoxicity and increased 73% hyperparathyroidism risk of bleeding with uremic platelet dysfunction. Diabetic neuropathy Paracetamol is safe and requires no dose adjustment Polycystic kidney disease for renal failure. Calciphylaxis (hemodialysis Morphine: active metabolite accumulates in CKD 5 patients only) and can cause neurotoxicity. Use lower dose and/or longer dosing interval than usual. Anorexia Nausea (see below) Anti-emetics (see below). 71% Diabetic gastroparesis Metoclopramide for gastroparesis. Dry mouth Oral care. Steroid to stimulate appetite. Swelling in Fluid overload Elevate edematous extremities. legs/arms Low oncotic pressure due to Elastic wraps as tolerated. 71% proteinuria and malnutrition If comfort and quality of life are the only goals of Comorbid heart failure care, not preservation of renal function, diurese for symptomatic peripheral edema or anasarca. Dry mouth Intravascular volume depletion Instruct family caregivers to keep mouth moist with 69% (can exist even with total body sips of liquid or sponge. fluid overload). 148ȀƢȀchronic care integration for endemic non-communicable diseases
Physical symptom Cause Treatment (see Chapter 2 for details) Constipation Medications including opioids Laxative 65% and anticholinergics Intravascular volume depletion Nausea with or Uremia Reduce or eliminate culprit medications, if possible. without vomiting Emetogenic medications Haloperidol for nausea due to endogenous or exog- 59% Diabetic gastroparesis enous emetogenic toxin. Start with low dose. Metoclopramide for gastroparesis. Cough Pulmonary edema If comfort and quality of life are the only goals of 47% Aspiration care, not preservation of renal function, diurese for symptomatic pulmonary edema. Comorbid COPD or other lung pathology 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 Anxiety Psychosocial supports 78% Haloperidol Diazepam (can cause delirium and paradoxical agitation) Feeling sad Psychosocial supports 65% Depression Psychosocial supports Unknown prevalence Antidepressant such as fluoxetine or amitriptyline
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6.9 Acute Kidney Failure in Hospitalized Patients H8)*':$9"$.'5&4*'9'$55%4**':$9$A4:49#'&6'$+"#4'%49$.'6$)."%4')9' 8&*-)#$.)^45'-$#)49#*>'_4'%464%'#&'#84'6&%#8+&:)9A'_,b'5)*#%)+#'+.)9)+)$9' :$9"$.'6&%'$5&.4*+49#*'$95'$5".#*> chapter!6 | chronic kidney diseaseȀƢȀ151
Chapter 6!References
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TABLE 7.1 Diabetes Diagnosis: Blood Sugar Measurement and Symptoms
Blood sugar η 126 mg/dL (7 mmol/L) fasting OR η 200 mg/dL (11 mmol/L) random with symptoms OR η 200 mg/dL (11 mmol/L) with an oral glucose tolerance test Glycosylated hemoglobin (HbA1c) η 6.5% (using a point-of-care device)
Symptoms of chronic hyperglycemia Polyuria (excessive urination) Polydipsia (excessive thirst) Weight loss PROTOCOL 7.1
Present to acute care clinic with any of the following symptoms: Any 1. Dehydration Hyperglycemia unlikely to Check a urine glycosuria or 2. Frequent urination NO be cause of symptoms. dipstick unable to 3. Thirst check Consider other etiologies
4. Increased appetite 5. Weight loss or gain YES at Health-Center Level Diagnosis ofDiabet
Check a finger stick blood glucose NO
Blood sugar ≥ 150 mg/dL (8.3 mmol/L) es and Management of Hyperglycemia Hyperglycemia of Management and es
YES 1. Adults: give 500 ml normal saline (NS) bolus, then continue NS at 250 cc/hour. Children ≤ 12 years old: give 20 ml/kg NS Blood sugar bolus, then continue at maintenance dose Immediately ≥ 400 mg/dL (22 mmol/L)? YES 2. Give 0.2 U/kg (or 10 units for an adult) SC transfer to hospital of regular insulin 3. Check blood sugar every hour and give additional insulin until transfer (Table 7.3)
NO
YES
Any warning signs: chapter 1. Slow, deep breathing Consider other Blood sugar 2. “Fruity” breath causes of the 3. Abdominal pain, nausea, vomiting YES 200-400 mg/dL NO patient’s symptoms (11–22 mmol/L)? 4. Sleepy, not responding and transfer to ! ≤ 7 5. Blood pressure 90/60 mmHg hospital |
diabetes NO
Likely type 1 diabetes mellitus, Likely type 2 or mixed diabetes mellitus, refer refer to district hospital for inpatient confirmation of YES Age ≤ 18 NO to district NCD clinic for confirmation of ȀƢȀ diagnosis and likely initiation of insulin therapy diagnosis and initiation of oral hypoglycemics 157 (Protocol 7.2) 158ȀƢȀchronic care integration for endemic non-communicable diseases
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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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TABLE 7.3 Insulin Therapy of Patients with Hyperglycemia (η 250 mg/dL) and Danger Signs Awaiting Transfer
Blood sugar Regular insulin dose (given subcutaneously)
For children (ζ 40 kg) For adults
Initial bolus 0.2 units/kg x 1 10 units
Recheck blood glucose every hour
η 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
ζ 150 mg/dL (ζ!8 mmol/L) Stop insulin, continue normal saline or lactated ringers
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TABLE 7.4 Diagnosis and Treatment of Hypoglycemia
Symptoms Somnolence or agitation Confusion Lethargy Dizziness, nausea Seizures Stroke-like symptoms Sweating Tremors Palpitations, anxiety
Causes Correctable: Overdose of medication (insulin or orals) Increased exercise Skipped 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 ζ 12 give glucose 50% solution by nasogastric tube (if unable to follow commands) 3–12 hours of frequent finger-stick checks
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TABLE 7.5 Glucose Control Goals
Reasonable control More intensive control
Pre-meal and 150–180 mg/dL 120–150 mg/dL pre-bedtime glucose (8.3–10 mmol/L) (6.7–8.3 mmol/L)
Hemoglobin A1c 7.5%–8%: 7.0%–7.5%: average blood glucose of average blood glucose of 170–185 mg/dL 154–170 mg/dL (9.4–10.5 mmol/L) (8.6–9.4 mmol/L)
7.3.1 Oral Hypoglycemic Agents U@49')9'.&<2)9+&:4C'.&<2!R?'*4##)9A*C':$97'-$#)49#*'<)#8'5)$34#4*'<)..' %4*-&95'<4..'#&'&%$.'87-&A.7+4:)+':45)+$#)&9*>'H84*4':45)+)94*'$%4' 5%$:$#)+$..7'+84$-4%'#8$9')9*".)9C'4$*)4%'#&'"*4C'$95'.4**'5$9A4%&"*>' a9.4**'#84'-$#)49#')*'"954%'/g'74$%*'&.5'&%'8$*'8$5'P4#&$+)5&*)*C'&%$.' ϐǤǡ 4E-4%#*'5&'9'%4+&::495'"*4'&6'&%$.'#84%$-7')9'-%4A9$9+7'-495)9A' 6"%#84%'*#"57>'PROTOCOL 7.2'&"#.)94*'#84'$--%&$+8'#&'&%$.'#84%$-7'' &6'5)$34#4*>' PROTOCOL 7.2 Patient in district NCD clinic with confirmed diabetes, not on insulin
1. Start NS at 250 cc/hour 1. Any warning signs (see Table 7.2 )
2. Give 0.2 U/kg (or 10 units for an adult) SC of regular insulin if Adults) (in Agents Hypoglycemic Oral with Diabetes Treatmentof AND glucose ≥ 200 mg/dL (11 mmol/L) YES glucose ≥ 250 mg/dL (13.8 mmol/L) OR 3. Check blood sugar every hour and give additional insulin until 2. Glucose ≥ 400 mg/dL (22.2 mmol/L) transfer (see Table 7.3)
NO
Hypoglycemia Glucose First visit or Maximum dose of Refer to district clinic (see Table 7.4) control at goal? not on NO NO NO glibencamide and YES for insulin therapy ≥ 2x since last visit (see Table 7.5) therapy? metformin Stop glibenclamide
YES YES
YES NO BMI ≥ 25 kg/m! Correctable cause of hypoglycemia?
YES YES NO
NO Start chapter Continue current metformin Continue current diabetes Increase dose 500 mg daily. Decrease dose diabetes medications. medications (see Table 7.6) Encourage (see Table 7.6). Ensure access to regular Encourage meals/snacks.
weight loss ! regular meals Nutritional support 7
if needed |
diabetes Start glibenclamide, 5 mg in the morning ȀƢȀ 163 Follow-up 2–4 weeks Follow-up 4–8 weeks 164ȀƢȀchronic 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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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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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 ζ 18 years of age PROTOCOL 7.3
Diabetes mellitus Treat infection, OR change insulin batch, AND OR ensure good insulin storage Already on insulin and injection techniques. OR Has new indication for insulin therapy (see Table 7.8) YES
1. Adults: give 500 ml normal saline (NS) bolus, then Initiation andAdjustment ofInsulinRegimens 1. Any Warning Signs (see Table 7.2) continue NS at 250 cc/hour. Children ≤ 12 years old: give Correctable AND 20 ml/kg NS bolus, then continue at maintenance dose cause of glucose ≥ 200 mg/dl (11 mmol/L) YES 2. Give 0.2 U/kg (or 10 units for an adult) SC of hyperglycemia? OR regular insulin if glucose ≥ 250 mg/dL (13 mmol/L) (see Table 7.7) 2. Glucose ≥ 400 mg/dl (22.2 mmol/L) 3. Check blood sugar every 1–4 hours and give additional insulin until transfer (see Table 7.3) NO NO
If on oral medications: 1. Stop glibenclamide Increase insulin 2. Continue metformin (see Table 7.10)
NO
Follow-up 2–4 weeks Glucose Identify insulin Decrease insulin First visit NO control at goal? NO regimen Hypoglycemia? (see Table 7.10) for insulin (see Table 7.5) (started as inpatient)
YES NO YES YES Correctable chapter cause of hypoglycemia? (see Table 7.4)
Refer to ! Continue current 7 hospitalfor diabetes medications. |
admission Follow-up 4–8 weeks diabetes
YES ȀƢȀ Ensure access to regular meals/snacks. Nutitional support as needed. 167 168ȀƢȀchronic care integration for endemic non-communicable diseases
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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 Once or twice daily, 20–30 minutes before breakfast before meals around 7 am and 7 pm and/or dinner (or bedtime)
Vial appearance Clear Cloudy Cloudy (manufacturer-specific)
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TABLE 7.10 Insulin Regimens 0.5–0.7 units/kg 0.5–0.7 0.5–0.7 units/kg 0.5–0.7 0.3–0.6 units/kg/day: units/kg/day: 0.3–0.6 50% pre-breakfast, 50% pre-dinner meal) before (20–30 minutes 0.3–0.6 units/kg/day: 0.3–0.6 60% pre-breakfast, 40% pre-dinner meal) before (20–30 minutes 0.2 units/kg/day or 0.2 units/kg/day is (whichever 10 units/day at bedtime given less) 0.2–0.3 units/kg 0.2–0.3 50% of dose as NPH Give regular with dinner-time combined One dose pre-dinner insulin 50% of dose as regular Give meals) prior to 20-30 minutes and given evenly (split 0.2–0.3 units/kg 0.2–0.3 50% of dose as NPH Give 60% pre-breakfast 40% pre-dinner 50% of dose as regular Give and pre-dinner, pre-breakfast evenly (split meal) before 20–30 minutes Not appropriate Not appropriate Not appropriate Starting 1 dose type Starting2 dose type Dinner-time NPH and regular NPH and regular Dinner-time alone with Regular combination. and lunch breakfast Allows patients to control mix control patients to Allows two insulin from combine Patients and give vials (NPH and regular) the injection 2x/day Post-prandial hyperglycemia. For For hyperglycemia. Post-prandial need diets, may high-carbohydrate mix a 50/50 closer to Good for some patients with type some patients with type Good for with problem but again 2 diabetes, diet if high-carbohydrate coverage Most simple, but not good coverage coverage Most simple, but not good diet if high-carbohydrate Notes dinner Lunch may by be covered morning NPH dinner (no lunch coverage) Coverage Coverage at meals Coverage Coverage of basal glycemia 2 Good and Breakfast 2 Good and Breakfast 2 Good None 1 Some None
) ) rapide mixte ) and ) 1x/day ) 2x/day ) insulatard insulatard insulatard lente lente lente Basal/Prandial 3 Good All meals meals midday large Best for NPH ( or ( regular Insulin 2x/day 70/30 ( 70/30 2x/day NPH ( or NPH ( or Regimen Injections chapter!7 | diabetesȀƢȀ171
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TABLE 7.11 Example of Glucose Monitoring Chart Insulin 57 mg/dL 57 72 mg/dL 72 Blood sugar Before bedtime Before
None None None None Symptoms of hyperglycemia/ hypoglycemia 2U Regular 7U NPH 2U Regular 2U Regular 7U NPH 2U Regular Insulin 150 mg/dL 7U NPH 125 mg/dL 7U NPH Blood sugar Before dinner Before
Symptoms of hyperglycemia/ hypoglycemia 2U Regular2U None Regular2U None 2U Regular2U None Insulin 204 mg/dL 240 mg/dL 240 Regular 2U None Blood sugar Before lunch Before
Symptoms of hyperglycemia/ hypoglycemia 2U Regular2U None 2U Regular2U None Insulin 170 mg/dL 170 Regular 2U None 183 mg/dLRegular 2U None Blood sugar Day Day 4 Day Day 2 Day 3 Day Day 1 Date breakfast Before chapter!7 | diabetesȀƢȀ173
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TABLE 7.12 Principles for Adjusting Insulin 70/30 (Mixte) or 2x/day NPH Regimens
Timing of hyperglycemia/ Hyperglycemia Hypoglycemia hypoglycemia (documented) (documented OR symptoms)
Morning/overnight Increase dinner-time or evening Decrease dinner-time or evening insulin by 2 units 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
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TABLE 7.13 Principles for Adjusting Combined Basal (NPH) and Prandial (Regular Insulin) Regimens
Hyperglycemia Hypoglycemia (documented) (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 Decrease Pre-Dinner Regular 2 U Regular 2–4 U
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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)
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TABLE 7.15 Common Complications of Diabetes and Their Prevalence in Some African Cohorts
Prevalence52-54 Mode of evaluation Frequency of Action if abnormal evaluation
Peripheral 35%–70% Monofilament Once yearly Intensify treatment neuropathy sensory testing of the regimen if possible. feet. If a microfila- Consider treating ment is not available, neuropathic pain proprioception can with amitriptyline be tested. Patients 25 to 100 mg per may also complain day orally. Shoes if of neuropathic pain needed. Counsel on (burning, electrical foot protection sensations) in the feet
Foot ulcer 1.7%–10% Visual inspection, n/a Referral to district probe evaluation to hospital for possible rule out osteomyelitis debridement and broad-spectrum antibiotics Retinopathy or 5%–35% Fundoscopic Once every 3 years, Intensify treatment sight-threatening evaluation or retinal performed at a district regimen if possible. eye disease photography hospital with an Referral for evalua- ophthalmic clinical tion at an ophthalmic o$cer. More frequent center if needed for follow-up if estab- intervention lished retinopathy.
Cataracts 8.7%–25% Fundoscopic Once every 3 years Referral for evaluation evaluation performed at a district at an ophthalmic hospital with an center for intervention ophthalmic clinical o$cer Albuminuria 18% Urine dipstick Every six months Intensify treatment regimen if possible. Add an ACE inhibitor (e.g., lisinopril, 5 mg per day orally) Nephropathy 19%–34% Serum creatinine Yearly Intensify treatment testing regimen if possible. Add an ACE inhibitor if no counterindica- tion (e.g., lisinopril, 5 mg per day orally)
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7.8.1 Community Health Workers and Accompaniment' H$P)9A'#84'%)A8#'#7-4'&6')9*".)9')9'#84'%)A8#'5&*4'$#'#84'%)A8#'#):4'+$9'34' ϐ Ǥ 84$.#8'<&%P4%*'-%&@)54'$**)*#$9+4>'H847'84.-'49*"%4'#8$#'-$#)49#*'$%4' #$P)9A'#84)%')9*".)9'+&%%4+#.7'$95':&9)#&%'6&%'*7:-#&:*'&6'87-4%A.7+4:)$' $95'87-&A.7+4:)$>'H847'$.*&':$P4'*"%4'-$#)49#*'5&'9':)**'$--&)9#:49#*' &%'%"9'&"#'&6':45)+$#)&9*>'S&::"9)#7'84$.#8'<&%P4%*'$.*&'*4%@4'$*'#84' P44-4%*'&6'%4.$#)@4.7'*+$%+4'A."+&:4#4%*h'#847'+$9')9#49*4.7':&9)#&%'$' ǯ ϐ %4A):49''H847'+$9'$**)*#'-$#)49#*')9'+84+P)9A'3.&&5'A."+&*4'%4$5)9A*C' ):-%&@4'+&:-.)$9+4'$95'$584%49+4'#&'#%4$#:49#'%4A):49*C'$95'84.-' )549#)67'$95'%4.$7'-%&3.4:*'-$#)49#*':$7'34'8$@)9A'<)#8'#84)%'#84%$-)4*> chapter!7 | diabetesȀƢȀ181
7.8.2 Food Assistance H84'#):)9A'&6':4$.*')9'%4.$#)&9*8)-'#&'#84'5&*4'&6')9*".)9')*'@4%7'):-&%2 #$9#>'?6'$'-$#)49#'#$P4*')9*".)9'<)#8&"#'4$#)9AC'87-&A.7+4:)$'<)..'%4*".#>' U9*"%)9A'#8$#'-$#)49#*'&9')9*".)9'8$@4'*#$3.4'*"--.)4*'&6'6&&5')*'4**49#)$.>' H8)*':$7'34'$++&:-.)*845'37'-%&@)5)9A'6&&5'-$+P$A4*'#&'#84'-$#)49#=*' 6$:).7'&%'37'*"--&%#)9A'#84'6$:).7=*'$3).)#7'#&'A%&<'6&&5C'4)#84%'&9'#84)%' &<9'.$95'&%'&9'$'+&::"9)#7'-.C'#8%&"A8'-$#)49#'$**&+)$#)&9*>'L'6"..'*&+)$.' <&%P'4@$."$#)&9'&6'#84'6$:).7'*8&".5'34'5&94C'$*'#84'6$:).7'&6'$'-$#)49#' <)#8&"#'49&"A8'6&&5'<)..'&6#49'8$@4'T%':$.9&"%)*845':4:34%*> 182ȀƢȀchronic care integration for endemic non-communicable diseases
Chapter 7!References
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PROTOCOL 8.1 Initial Screening and Management of Hypertension in Acute Consultation Clinics
Any patient with a routine complaint BP ≥140/90 mmHg NO Address primary complaint presenting to acute care clinic x2 at rest
YES
Transient cause Address primary of HTN present YES (e.g., pain, complaint anxiety)
NO
Pregnant (all women See management of HTN between 15 and YES 49 should be in pregnancy (Protocol 8.5) tested)
NO
Give nifedipine immediate Danger signs: release 10 mg PO x 1 OR acute dyspnea, captopril 25 mg PO x 1. Transfer to BP ≥ 180/110 mmHg YES YES visual changes, Consider Lasix 20 mg IV OR district hospital headache? Lasix 40 mg PO x 1 if di!culty breathing
NO
NO Start two anti-hypertensives at initial dose, have follow-up in nearest health center CCC in 1 week. Communicate appointment to CCC nurse. Stage 2 Refer to nearest CCC clinic 160/100– in 1–4 weeks for evaluation YES 180/110 mmHg of HTN. Communicate appointment to CCC nurse.
NO
BP = Blood pressure YES CCC = Chronic care clinic HTN = Hypertension Stage 1 Return to acute care clinic 140/90–160/100 ≥ 6 mo trial of in 6 months for BP check. mmHg WITH 2 YES lifestyle NO Counsel on reducing salt or more high-risk modification intake and weight loss if features* appropriate. *High-Risk Features: - Age ≥ 65 years - Known diabetes - Known renal failure NO - BMI ≥ 25 kg/m" - Tobacco smoking
Lone Stage 1 Return to acute care 140/90–160/100 clinic in 12 months for BP mmHg WITHOUT YES check. Counsel on reducing salt intake and high-risk features* weight loss if appropriate.
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TABLE 8.1 High-Risk Features in Hypertension
High-risk feature Points
Diagnosis of diabetes 2
Diagnosis of renal failure (creatinine η 1) 2
Age η 65 years 1
BMI η 25 kg/m2 1
Tobacco smoking 1
A total of 2 or more points is considered high risk and warrants more aggressive treatment.
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Start one drug ȀƢȀ at lowest dose. Meets criteria chronic careintegration for endemic non-communicable diseases Stage 1 Return to for CCC referral: YES (140/90–160/100 health center Patient (1) BP ≥ 160/100 mHg OR Refer patient back to mmHg) CCC in 3 referred to (2) BP ≥ 140/90 mmHg AND urgent care setting for NO months health center ≥ 2 high risk points* AND BP recheck in 6–12 CCC for HTN failed trial of lifestyle months NO modification
Check urine ≥ in HealthCenter Integrated Chronic Care Clinics Cases Hypertension Referred Newly of Management Initial PROTOCOL 8.2 8.2 YES BMI 25? #49*)&9'+$*4*')9')9#4A%$#45'+8%&9)+'+$%4'+.)9)+*>' dipstick YES
BP ≥ 180/110 mmHg in HealthCenter Integrated Chronic Care Clinics Cases Hypertension Referred Newly of Management Initial AND Manage as hypertensive emergency danger signs: YES (Section 8.4, Table 8.4) Check creatinine and acute dyspnea, visual changes, prioritize ACE-I if not headache? ≥ 2+ proteinuria YES contraindicated (i.e., pregnancy or creatinine ≥ '&"#.)94*'#84')9)#)$.':$9$A4:49#'&6'94<.7'%464%%45'87-4%2 200 µmol/L)
NO NO Check a confirmatory test Complete intake form, Transfer to for diabetes evaluate for complicating/comorbid district hospital (fasting blood glucose or factors Any glycosuria YES hemoglobin A1C). If diabetes confirmed, BP goal will be ≤ 130/80 mmHg (Chapter 7) Refer to NCD NO Signs of clinic for heart failure YES suspected heart 1. If ≤ 40, check for causes of (edema, dyspnea) failure secondary HTN Stage 2 (Protocol 4.1) 2. Start two drugs at lowest 160/100– YES dose NO 180/110 mmHg 3. Return to health center CCC Evaluate hypertension stage in 3 months. See NO Pregnant? management of (women between 15 and YES hypertension in 49 should be tested) pregnancy (Protocol 8.5) Stage 3 Refer to district-level ≥ 180/110 YES NCD clinic in 1–2 weeks NO mmHg BP = Blood pressure CCC = Chronic care clinic See
HTN = Hypertension management of diabetes In district NCD clinic: Diabetic YES (Chapter 7) 1. Evaluate for signs of heart failure. If present perform BP goal will be an echo * High-Risk Features: ≤ 130/80 mmHg 2. Check creatinine Diabetes – 2 points 3. If ≤ 40, consider checking for other causes of Renal failure – 2 points NO secondary HTN Proteinuria – 2 points 4. Start two drugs at lowest dose. Tobacco smoking – 1 point 5. If no renal or heart failure, refer back to health center ≥ BMI 25 – 1 point CCC for visit in 1–2 weeks. Otherwise, return to Age ≥ 65 years – 1 point district NCD clinic in 1–2 weeks. chapter!8 | hypertensionȀƢȀ195
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TABLE 8.2 Initiation of Hypertension Treatment According to Stage and Risk Factors
Stage Blood pressure Treatment Clinic follow-up range Stage 1 140/90–160/100 Do not start medications. 12 months in AND mmHg Counsel on salt intake and acute care ζ 1 high risk point (TABLE 8.1) weight loss if indicated.
Stage 1 140/90–160/100 Do not start medications. 6 months in AND mmHg Counsel on salt intake and acute care η 2 high risk points (TABLE 8.1) weight loss if indicated. AND No trial of lifestyle modification
Stage 1 140/90–160/100 Start first-line medication 3 months in health AND mmHg at lowest dose center integrated chronic care clinic η 2 high risk points (TABLE 8.1) AND Failed 6-month trial of lifestyle modification
Stage 2 160/100–180/110 Start first- and second-line 3 months in health mmHg medications at lowest dose center integrated chronic care clinic Stage 3 η180/110+ mmHg Start first- and second-line 1–2 weeks in district WITHOUT medications at lowest dose level NCD clinic Danger signs* Stage 3 η180/110+ mmHg Initiate therapy listed in WITH TABLE 8.4. Transfer to district hospital for inpatient Danger signs* management
* Danger signs include acute dyspnea, visual changes, headaches.
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TABLE 8.3 Recommended Hypertension Medications and Dosing for Most Adult Patients
First-line drug Starting dose Increase Maximum Notes dose by dose 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 η 300 µmol/L)
Second-line drug Starting dose Increase Maximum Notes dose by dose Amlodipine 5 mg 1x/day 5 mg 1x/day 10 mg 1x/day Can cause lower-extremity edema
Third-line drug Starting Dose Increase Maximum Notes dose by dose Lisinopril 5 mg 1x/day 5 mg 1x/day 20 mg 1x/day Contraindicated in pregnancy and advanced renal failure η Captopril 12.5 mg 3x/day 12.5 mg 3x/day 50 mg 3x/day (creatinine 200 µmol/L) Can cause cough Fourth-line drug Starting dose Increase Maximum Notes dose by dose Atenolol 25 mg 1x/day 25 mg 1x/day 50 mg 1x/day Contraindicated if heart rate η 55 bpm Use with caution in renal failure, since atenolol is renally cleared Fifth-line drug Starting dose Increase Maximum Notes dose by dose Hydralazine 25 mg 3x/day 25 mg 3x/day 50 mg 3x/day Safe in pregnancy Headache common side e#ect of hydralazine Methyldopa 250 mg 2x/day 250 mg 2x/day 500 mg 2x/day Safe in pregnancy
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TABLE 8.4 Recommended Medications for Management of Hypertensive Emergency (Adult Dosing)
Medication Dosing Notes
Nifedipine 10 mg orally (immediate release)
Captopril 25 mg orally Contraindicated in pregnancy and severe renal failure (Cr η 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*' ϐǡ :$7')9+%4$*4>',7-4%#49*)&9':$7'$.*&'.4$5'#&'%49$.'6$)."%4'37'-"##)9A' ǯϐǤ2 *"%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-.$)945'34.&<> 202ȀƢȀchronic care integration for endemic non-communicable diseases
TABLE 8.5 Hypertension Medications and Dosing in Setting of Proteinuria or Mild Renal Failure (Creatinine 100–200 !mol/L)
First-line drug Starting dose Increase Maximum Notes dose by dose Lisinopril 5 mg 1x/day 5 mg 1x/day 20 mg 1x/day Contraindicated in pregnancy and advanced renal failure (creatinine η 200 µmol) Captopril 12.5 mg 3x/day 12.5 mg 3x/day 50 mg 3x/day Can cause cough
Second-line drug Starting dose Increase Maximum Notes dose by dose Hydrochlorothiazide 12.5 mg 1x/day 12.5 mg 1x/day 25 mg 1x/day Can cause hypokalemia Not e#ective in the setting of severe renal failure (creatinine η 300 µmol) Third-line drug Starting dose Increase Maximum Notes dose by dose Amlodipine 5 mg 1x/day 5 mg 1x/day 10 mg 1x/day Can cause lower-extremity edema
Fourth-line drug Starting dose Increase Maximum Notes dose by dose Atenolol 25 mg 1x/day 25 mg 1x/day 50 mg 1x/day Contraindicated if heart rate ζ 55 bpm Use with caution in renal failure as is renally cleared Fifth-line drug Starting dose Increase Maximum Notes dose by dose Hydralazine 25 mg 3x/day 25 mg 3x/day 50 mg 3x/day Safe in pregnancy. Headache common side e#ect
Methyldopa 250 mg 2x/day 250 mg 2x/day 500 mg 2x/day Safe in pregnancy
8.5.1 Proteinuria or Mild Renal Failure (Creatinine between 100–200 !mol/L) G%)9"%)$')*'$9'4$%.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' ǤϐǦ $..'-$#)49#*'<)#8'-%)9"%)$'&%':).5'%49$.'6$)."%4'"9.4**'+&9#%$)95)+$2 Ǥ ηʹͲͲ ρȀȋηʹǤ͵ȀȌ > chapter!8 | hypertensionȀƢȀ203
TABLE 8.6 Recommended Hypertension Medications and Dosing in Setting of Severe Renal Failure (Creatinine η 200 !mol/L)
First-line drug Starting dose Increase Maximum Notes dose by dose If Cr Hydrochlorothiazide 12.5 mg 1x/day 12.5 mg 1x/day 25 mg 1x/day Can cause ζ 300 hypokalemia µmol/L If Cr Furosemide 20 mg 1x/day 20 mg 1x/day 40 mg 1x/day η 300 µmol/L Second-line drug Starting dose Increase Maximum Notes dose by dose Amlodipine 5 mg 1x/day 5 mg 1x/day 10 mg 1x/day Can cause lower- extremity edema
Third-line drug Starting dose Increase Maximum Notes dose by dose Atenolol 25 mg 1x/day 25 mg 1x/day 100 mg 1x/day Contraindicated if heart rate ζ 55 bpm Use with caution in renal failure Fourth-line drug Starting dose Increase Maximum Notes dose by dose Hydralazine 25 mg 3x/day 25 mg 3x/day 50 mg 3x/day Safe in pregnancy Headache common side e#ect Methyldopa 250 mg 2x/day 250 mg 2x/day 500 mg 2x/day Safe in pregnancy
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8.6 Evaluation and Management of Hypertension in Younger Patients R&*#'4**49#)$.'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
Patient ≤ 40 years old Check creatinine Hypertension likely and SBP ≥ 160 mmHg and potassium Creatinine ≥ 200 µmol/L YES secondary to renal and DBP ≥ 100 mmHg (if available) failure. See Section 8.5
NO
Evaluate for other causes of secondary hypertension and refer to endocrinologist 1. Cushingnoid features 2. 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)
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TABLE 8.7 Causes of Secondary Hypertension
Cause Findings Management
Renal failure Elevated creatinine (η 200) See SECTION 8.5
Cushing’s syndrome Truncal obesity, round face, extremity Refer to tertiary referral center for (hypercortisolism) wasting, hypokalemia endocrinology consultation
Hyperaldosteronism Hypokalemia Refer to tertiary referral center for endocrinology consultation
Pheochromocytoma Periodic episodes of hypertension, Refer to tertiary referral center for anxiety, tachycardia, diaphoresis endocrinology consultation
Coarctation Delayed or absent femoral pulse; SBP in Refer to tertiary referral center for legs 40 mmHg ζ than SBP in arms echocardiography and cardiology consultation Renal artery stenosis Abdominal bruit; creatinine more than Refer to tertiary referral center for renal doubles after starting ACE inhibitor ultrasound and nephrology consultation chapter!8 | hypertensionȀƢȀ205
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)+'+$%4'+.)9)+*'6&%'87-4%#49*)&9>'
PROTOCOL 8.4 Follow-Up Visit for Chronic Hypertension in Health Center Integrated Chronic Care Clinic
Patient on medications for hypertension
BP ≥ 180/110 mmHg AND Treat as hypertensive emergency Transfer to YES danger signs: (Section 8.4 and Table 8.4) district hospital acute dyspnea, visual changes, headache?
NO
Complete follow-up form
Pregnant? See management of (Test women 15–49 if YES hypertension in pregnancy suspected) (Section 8.8)
NO
Evaluate hypertension stage
Continue current therapy. Controlled Return to health center CCC in (BP ≤ 140/90 YES 3–12 months depending on mmHg) health center refill mechanism
NO
Stage 1 Start or increase one drug by one interval. BP 140/90– YES 160/100 mmHg Return to health center CCC in 3 months
NO
Check creatinine and prioritize Urine dipstick ACE inhibitor if not contraindicated NO Check urine dipstick ≥ 2+ proteinuria YES checked in past (i.e., pregnancy or year? creatinine ≥ 200 µmol/L)
NO
Check a confirmatory test for diabetes Any glycosuria YES (fasting blood glucose or YES hemoglobin A1C)
NO
Stage 2 Start or increase two drugs by one interval. 160/100 – YES 180/110 mmHg Return to health center CCC in 3 months
NO
Stage 3 Start or increase two drugs by one interval. ≥ 180/110 YES Consider assigning a community health worker mmHg Refer to district level NCD clinic in 1–2 weeks
BP = Blood pressure CCC = Chronic care clinic 206ȀƢȀchronic care integration for endemic non-communicable diseases
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8.7.1 Management of Well-Controlled Hypertension on Follow-Up G$#)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)+' Ǥ ǡϐ :".#)2:&9#8'*"--.)4*'&6':45)+$#)&9'<)#8&"#'+$"*)9A'*#&+P2&"#*>'H84%42 6&%4C'#84'#):4'34#<449'+.)9)+'@)*)#*'<)..'54-495':&*#.7'&9'#84'5)*-49*)9A' ϐ Ǥ
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 Hypertension G$#)49#*'<)#8'*#$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$#)9)94'.4@4.'' ζʹͲͲρȀ2 Ǥ ϐ ǡ ͳ ϐǦ Ǥ
8.7.4 Follow-Up of Stage 3 Hypertension G$#)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'$97'A.7+&*"%)$' ϐǡ ͳ ϐǦ Ǥ ǡ 9445'+.&*4%'6&..&<2"-'$95'*8&".5'34'A)@49'$9'$--&)9#:49#'<)#8)9'/kJ' Ǥϐ <&%P4%'#&'-%&@)54'*"--&%#'$95'49*"%4'A&&5':45)+$#)&9'$584%49+4>'
8.8 Hypertension in Pregnancy ,7-4%#49*)@4'5)*&%54%*'$++&"9#'6&%'$--%&E):$#4.7'dm'&6'#$.':$#4%9$.' :&%#$.)#7')9'L6%)+$>/K'H84':$9$A4:49#'&6'#84*4'+&95)#)&9*')*'+&:-.)2 +$#45'37'#84'6$+#'#8$#':$97'+&::&9'$9#)87-4%#49*)@4*'+$"*4'3)%#8' 5464+#*>'[4<'+.)9)+$.'#%)$.*'8$@4')9@4*#)A$#45'#%4$#:49#'&6'87-4%#49*)&9' chapter!8 | hypertensionȀƢȀ207
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ϐ A4*#$#)&9$.'$A4'&6'-%4A9$9+7>',&<4@4%C'$++"%$#4'-%4A9$+7'5$#)9A'+$9'34' ϐ ǦǤ &6'A4*#$#)&9$.'$A4C'$95'*4@4%$.'*#"5)4*'8$@4'*8&<9'#84*4':4$*"%4:49#*' +$9'34'4$*).7'#$"A8#>/d'?9'*4##)9A*')9'<8)+8'$9'".#%$*&"95')*'9'$@$).$3.4' $95'.$*#':49*#%"$.'-4%)&5')*'9'$++"%$#4.7'P9&<9C'6"95$.'84)A8#':$7' 34'"*45'$*'$'-%&E7'6&%'A4*#$#)&9$.'$A4>J1CJ/'Y)9+4':&*#'+&:-.)+$#)&9*'&6' 87-4%#49*)&9')9'-%4A9$9+7'&++"%'$#'A%4$#4%'#8$9'BK'<44P*'&6'A4*#$#)&9$.' $A4C'"*)9A'$'+&9@4%@$#)@4'#8%4*8&.5'&6'J1'+:'6"95$.'84)A8#'V#7-)+$..7' 4O")@$.49#'#&'J1'<44P*'A4*#$#)&9$.'$A4X'*8&".5'A"$%$9#44'$++4-#$3.4' *49*)#)@)#7>' 208ȀƢȀchronic care integration for endemic non-communicable diseases
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H%$5)#)&9$..7C'5)$*#&.)+'3.&&5'-%4**"%4'8$*'3449'"*45'#&'A")54'#%4$#:49#' )9)#)$#)&9')9'-%4A9$9+7C'$*')#'*44:*'#&'34##4%'+&%%4.$#4'<)#8'%)*P'&6'[email protected] &-)9A'*4)^"%4*>/]',&<4@4%C'%4+49#'*#"5)4*'*8&<'#8$#'*7*#&.)+'3.&&5'-%4*2 *"%4'+&%%4.$#4*'34##4%'<)#8'%)*P'&6':$#4%9$.'*#%&P4>/Z'?9'&"%'-%&+&.*C' <4'8$@4')9+."545'3'5)$*#&.)+'$95'*7*#&.)+'3.&&5'-%4**"%4'$*'+%)#4%)$' 6&%'#%4$#:49#')9)#)$#)&9> chapter!8 | hypertensionȀƢȀ209
TABLE 8.8 Hypertensive Disorders of Pregnancy
Classification Definition Risks Role of antihypertensives
Chronic BP η 140/90 mmHg η 20% will develop Does not reduce the risk of 22 hypertension AND preeclampsia developing preeclampsia Diagnosis of hypertension prior Placental abruption May reduce risk of maternal to pregnancy or before 20 weeks Intrauterine growth cerebral hemorrhage of gestation retardation Gestational BP η 140/90 mmHg 50% will develop Does not reduce the risk of 23 hypertension AND preeclampsia developing preeclampsia Diagnoses or progression of 10% will develop May reduce risk of maternal hypertension after 20 weeks severe preeclampsia cerebral hemorrhage of gestation WITHOUT Significant proteinuria Defined as η 2+ on a urine dipstick Preeclampsia BP η 140/90 mmHg 25% will develop Does not reduce the risk of AND severe preeclampsia developing severe preeclampsia Diagnosis or progression of Eclampsia (seizures) hypertension after 20 weeks Maternal stroke May reduce risk of maternal of gestation cerebral hemorrhage AND Significant proteinuria Defined as η 2+ on a urine dipstick Severe Preeclampsia Eclampsia (seizures) Does not reduce the risk of preeclampsia AND Maternal stroke developing severe preeclampsia BP η 160/110 mmHg May reduce risk of maternal OR hemorrhage η 3+ proteinuria OR Any symptom of end-organ damage (oliguria, right-upper-quadrant pain, severe persistent headache, cerebral hemorrhage, nausea, pulmonary edema, low platelets [ζ100,000], severe intrauterine growth restriction, or transaminitis [η twice normal])
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PROTOCOL 8.5 Management of Hypertension in Pregnancy
Woman with positive pregnancy test and blood pressure ≥ 140/90 mmHg x 2
Gestational age Initiate MgSO4 ≥ 20 weeks OR (Table 8.9) YES Seizures? YES able to palpate Transfer to district hospital uterine fundus at for immediate delivery umbillicus
NO
Check urine dipstick, evaluate for YES NO signs of preeclampsia or hypertensive emergency*
Manage as chronic hypertension using medications preferred in ≥ 3+ pregnancy (Table 8.11) ≥ Initiate antihypertensive proteinuria BP 160/110 YES mmHg treatment (Table 8.11) and/or danger signs?
NO NO * Symptoms of preeclampsia and/or hypertensive emergency BP 140/90– Danger Transfer to district hospital YES YES Dyspnea 160/110 mmHg signs? for prompt delivery Headache Visual changes Right-upper-quadrant pain Nausea/vomiting NO
Initiate anti- hypertensive ≥ 2+ treatment YES proteinuria (Table 8.11) Return to clinic in one week
NO
Recheck blood pressure at next prenatal visit
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8.8.1 Hypertension in Early Pregnancy (Chronic Hypertension) G%4A9$9+72)95"+45'87-4%#49*)&9'"*"$..7'&++"%*')9'#84'#8)%5'#%):4*#4%>' H84%46&%4C'-$#)49#*'<)#8'87-4%#49*)&9')9'#84'4$%.)4%'*#$A4*'&6'-%4A9$9+7' .)P4.7'8$@4'-%424E)*)#)9A'87-4%#49*)&9>',4%4C'<4'"*4'$'+"#2&66'&6'.4**' #8$9'J1'<44P*'A4*#$#)&9$.'$A4'$95i&%'$'6"95$.'84)A8#'.4**'#8$9'J1'+:'$*' ϐ Ǥ *):).$%'#&'#8$#'&6'9&92-%4A9$9#'87-4%#49*)@4*C'<)#8'#84'4E+4-#)&9'#8$#' 5)664%49#':45)+$#)&9*'$%4'-%464%%45'V*44'TABLE 8.11X>'H84*4'-$#)49#*'$%4' chapter!8 | hypertensionȀƢȀ211
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8.8.2 Hypertension in Later Pregnacy (Gestational Hypertension and Preeclampsia) G$#)49#*'<8&'54@4.&-'87-4%#49*)&9C'&%'<8&*4'87-4%#49*)&9'-%&A%4**4*' $#'A%4$#4%'#8$9'J1'<44P*'A4*#$#)&9$.'$A4C'$%4'$#'8)A84%'%)*P'&6'-%42 4+.$:-*)$'$95'4+.$:-*)$>'PROTOCOL 8.5'&"#.)94*'$9'$5$-#$#)&9'&6'#84' ?RGLS'$.A&%)#8):'6&%'4@$."$#)&9'$95'#%4$#:49#'&6'#84*4'-$#)49#*>/g
8.8.3 Recognition and Management of Emergent Conditions G$#)49#*'<8&'$%4'$+#)@4.7'*4)^)9A'&%'8$@4'8$5'*4)^"%4*'5"%)9A'.$#4'-%4A2 9$9+7'*8&".5'34')::45)$#4.7'*#$%#45'&9':$A94*)":'$95'#%$9*64%%45' #&'#84'94$%4*#'5)*#%)+#'8&*-)#$.'6&%')::45)$#4'54.)@4%7>'Y44'TABLE 8.926&%' .&$5)9A'$95':$)9#49$9+4'5&*)9A>
TABLE 8.9 Loading and Maintenance Dosing of Magnesium Sulfate in Eclampsia and Severe Preeclampsia (Adapted from IMPAC)17,18
Start with loading dose: Inject 4 grams (20 ml of 20% concentration) by IV over 20 minutes. AND Inject 5 grams (10 ml of 50% concentration) mixed with 1 ml of 1%–2% lidocaine IM in each buttock (for a total of 10 grams). If unable to establish IV, give only IM dose as loading dose. If seizures recur after 15 minutes, give reloading dose: Inject 2 grams of 20% concentration IV over 5 minutes. Follow with maintenance dose: Inject 5 grams of 50% concentration IM mixed with 1 ml of 1%–2% lidocaine in alternate buttocks every four hours. Maximum total dose: 40 g every 24 hours Side-effect monitoring: Monitor for respiratory depression (respiratory rate ζ 16), loss of reflexes and decreased urinary output (ζ100 ml/4 hrs). Injecting the magnesium too quickly increases the risk of respiratory or cardiac depression. Stop the therapy if the respiratory rate falls below 16 per minute, patellar reflexes are absent, or urinary output is less than 100 mL over 4 hours. For respiratory depression, give calcium gluconate 1 g IV (10 ml of 10% solution) over 10 minutes Other safety considerations Do not leave the patient by herself. Place her on her left side. Transfer immediately to district hospital unless delivery is imminent
8.8.4 Screening for Preeclampsia G$#)49#*'<)#8'9&'8)*#&%7'&6'*4)^"%4'$+#)@)#7'*8&".5'34'*+%44945'6&%'-%42' 4+.$:-*)$'<)#8'$'"%)94'5)-*#)+P'$95'4@$."$#)&9'&6'*7:-#&:*'&6'4952&%A$9' 212ȀƢȀchronic care integration for endemic non-communicable diseases
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8.8.5 Treatment of Preeclampsia According to Disease Classification Q0$0#02)#00'=";)1*"+'Y4@4%4'-%44+.$:-*)$')*'-%44+.$:-*)$'<)#8'$' ηͳͲȀͳͳͲ ǡǦǡ &%'A%4$#4%'#8$9'&%'4O"$.'#&'Bf'-%)9"%)$>'H84*4'-$#)49#*'*8&".5'34' *#$%#45'&9'$9#)87-4%#49*)@4*'$95'%4+4)@4'$'.&$5)9A'5&*4'&6':$A94*)":' 6&%'*4)^"%4'-%&-87.$E*)*C'<8).4'34)9A'-%4-$%45'6&%')::45)$#4'#%$9*64%' #&'#84'94$%4*#'5)*#%)+#'8&*-)#$.'6&%'-%&:-#'54.)@4%7>'`)645)-)94')*'#84' 6$*#4*#2$+#)9A'$9#)87-4%#49*)@4'#8$#')*'*$64')9'-%4A9$9+7>'H84'*4+&952.)94' $A49#C':4#87.5&-$C'8$*'$'.&9A4%'&9*4#'&6'$+#)&9'VTABLE 8.10X>
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TABLE 8.10 Recommended Medications for Management of Hypertension in Severe Preeclampsia
Medication Dosing Notes
Nifedipine (immediate release) 10 mg orally Fast acting
Methyldopa 250 mg orally Slower acting
8.8.5.1 Mild to Moderate Preeclampsia ϐηͳͶͲȀͻͲ ζͳͲȀͳͳͲ ǡηʹΪ &6'*4@4%4'-%44+.$:-*)$>'H84*4'-$#)49#*'*8&".5'34'*#$%#45'&9'$9#)87-4%2 #49*)@4*'$95'6&..&<45'+.&*4.7')9'#84'-%49$#$.'+.)9)+'VTABLE 8.11X>'?6'$' <&:$9')*'$.%4$57'&9'$9#)87-4%#49*)@4*C'*84'*8&".5'8$@4'84%':45)+$#)&9' 5&*$A4')9+%4$*45C'<)#8'$'A&$.'3.&&5'-%4**"%4'&6'/K1k/01id1k/11'::,A>' ?54$..7C'*84'<)..'34'$5:)##45'6&%'&3*4%@$#)&9'6&%'$#'.4$*#'$'JK28&"%'-4%)&5' $95'*84'*8&".5'34'A)@49'*#%)+#'-%4+$"#)&9$%7')9*#%"+#)&9*'#&'%4#"%9'#&' +$%4')::45)$#4.7')6'*84'54@4.&-*'$97'&6'#84'*7:-#&:*'&6'*4@4%4'-%42 4+.$:-*)$'&%'8$*'54+%4$*45'64#$.':&@4:49#>
8.8.5.2 Mild to Moderate Gestational Hypertension _&:49'<)#8':).5'87-4%#49*)&9'*8&".5'9'34'*#$%#45'&9':45)+$#)&9*>' G$#)49#*'$.%4$57'&9':45)+$#)&9*'*8&".5'+&9#)9"4'$9#)87-4%#49*)@4'#%4$#2 :49#'<)#8'5%"A*'$--%&-%)$#4'6&%'-%4A9$9+7> chapter!8 | hypertensionȀƢȀ213
TABLE 8.11 Recommended Hypertension Medications and Dosing in Pregnancy
First-line drug Starting dose Increase Maximum Notes dose by dose 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 Maximum Notes dose by dose Nifedipine 10 mg 3x/day 20 mg 3x/day 60 mg 3x/day (immediate release)
Amlodipine 5 mg 1x/day 5 mg 1x/day 10 mg 1x/day Can cause lower-extremity edema
Third-line drug Starting dose Increase Maximum Notes dose by dose Atenolol 25 mg 1x/day 25 mg 1x/day 100 mg 1x/day Contraindicated if heart rate ζ 55 bpm
Fourth-line drug Starting dose Increase Maximum Notes dose by dose Hydralazine 25 mg 3x/day 25 mg 3x/day 50 mg 3x/day Headache common side e#ect. Expensive, requires thrice-daily dosing 214ȀƢȀchronic care integration for endemic non-communicable diseases
Chapter 8!References
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FIGURE 9.1 Progression from Pharyngitis to Rheumatic Fever
Group A Pharyngitis 20% streptococcal 2% Rheumatic fever pharyngitis
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TABLE 9.1 Clinical Decision Rules for Treatment of Pharyngitis
% with GAS % without GAS not treated overtreated
Rule 1: WHO14 88% 6% Pharyngeal exudate + tender and enlarged cervical lymph nodes
Rule 2: Steinhoff12 10% 60% Pharyngeal exudate OR enlarged cervical lymph nodes
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PROTOCOL 9.1 Evaluation and Management of Pharyngitis
Patient with a sore throat
Assess for danger signs: 1. Leaning forward and drooling YES 2. Unable to swallow Refer to district hospital immediately 3. Stridor
NO
Treat as streptococcal pharyngitis Exudate? YES (see Tables 9.2 and 9.3)
NO
Child ≥ 2 of Following: between Treat as streptococcal 1. Lymphandenopathy 5 and 15 years YES YES pharyngitis 2. Documented fever ≥ 38 old? 3. Lack of cough (see Tables 9.2 and 9.3)
NO
Do not treat for streptococcus. NO Runny nose? Treat according to acute care Cough? YES guidelines for respiratory Congestion? complaints (see IMCI and IMAI guidelines)
NO YES Runny nose? Cough? Test for HIV if not recently tested Congestion? or if has risk factors
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TABLE 9.2 Antibiotic Regimens for Streptococcal Pharyngitis (Adults and Adolescents Dosing, Weight η 27 kg)
Regimen Doses Cost Allergic Reactions16,17
Oral penicillin VK 500 mg, two times per day 20 $0.66 Cutaneous 1%–2% for 10 days
Intramuscular benzathine 1.2 million units, single dose 1 $0.14 Cutaneous 1%–2% penicillin G Anaphylaxis 0.02%
Death 0.003%
Oral erythromycin 250 mg, four times per day 12 $6.38 (75 kg adult)
TABLE 9.3 Antibiotic Regimens for Streptococcal Pharyngitis (Pediatric Dosing, Weight ζ 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
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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) carditis Clinical 2. Polyarthritis or monoarthritis 1. Fever * 38˚C 3. Chorea 2. Arthralgia 4. Erythema marginatum Laboratory 5. Subcutaneous nodules 3. Elevated acute phase reactants (erythrocyte sedimentation rate * 30 mm/h) 4. PR-interval prolongation
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TABLE 9.5 Antibiotic Regimens for Secondary Prophylaxis of Rheumatic Fever
Adults ( η 27 kg) Children (ζ 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 600,000 units, once every 4 weeks 4 weeks Oral erythromycin (penicillin allergy) 250 mg, two times per day 10 mg/kg, twice per day
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TABLE 9.6 Echocardiographic Prevalence of Definite and Possible RHD in School-Aged Children
Country N Setting Population Definite or Possible probable RHD RHD Paar et al. 2010 41 Nicaragua 3150 Rural and Community 0.6% 2.4% urban
Steer et al. 2009 37 Fiji 3462 Rural and School-based 0.8% n/a urban
Carapetis et al. 2008 39 Tonga 5053 Rural and School-based 3.3% 0.5% urban
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 Kenya 1115 Rural and School-based 0.3% 7.3% 1996 42 urban
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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 Marijon et Preliminary World Health Organization/United Organization 2001 24 al. 2009 44 States National Institutes of Health 2005 37 Properties of Holosystolic (mitral) or Any degree Definite Probable regurgitant jet holodiastolic (aortic) in two planes regurgitation visible in η 2 cm, otherwise η 2 cm, otherwise at least two color planes meeting World Health meeting World Health with η 1 cm extension Organization 2001 Organization 2001 and a velocity η 2.5 m/s criteria* criteria*
Morphologic Not required Required** Required*** Not Required***† abnormalities
Pathologic Not required Not Required Required Required murmurs
* η 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 η 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.
!4+$"*4'&6'"9+4%#$)9#7'$3&"#'#84'):-&%#$9+4'&6':).5'.4*)&9*'&9'4+8&2 +$%5)&A%$-87C'<4'-%&-&*4'#8$#'-%4@$.49+4'*"%@47*'-.$+4':&%4'<4)A8#'&9' ϐǤǡ 4:-8$*)*'*8&".5'34'-"#'&9'4+8&+$%5)&A%$-8)+'5)$A9&*)*'V*44'TABLE 9.8X> PROTOCOL 9.2 9.8 TABLE ahlgcmrusNotrequired Pathologic murmurs Required* Morphologic abnormalities At leastmild-to-moderate regurgitation. Properties ofregurgitant jet High-risk group (Children ages 5–15) P 1. History: any recollection of severe joint pain, roposed Criteria for Definite and Possible RHD Possible and Definite for Criteria roposed
shortness of breath. Consider screening
questions for epilepsy, musculoskeletal Children) School-Aged of Conditions Other (and Scr disabilities, asthma eening for Rheumatic Heart Disease Disease Heart Rheumatic for eening 2. Physical examination: height and weight, auscultation. Consider physical examination for other conditions (e.g., skin infections) Regurgitation visibleinatleasttwo color planes Definite 3. Consider screening laboratory tests for anemia, proteinuria, HIV 4. Screening echocardiography (restricted to parasternal long and apical 4-chamber views). chapter
1. Initiate antibiotic prophylaxis (oral or IM) ! 9
2. Assign a community
Meet echocardiographic | Refer to district Definite YES YES health worker rheumatic heart diseaseprevention Criteria for definite or possible NCD clinic RHD? RHD? (see Table 9.5) 3. Monthly follow-up at health center chronic care clinic. NO
NO
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throat management Not Required Required* Any degree intwo planes Possible Follow-up plan for other 2. Participate in randomized identified conditions trial of antibiotics if available 3. Assign a community health worker 4. Follow-up every 6 months at district NCD clinic. ȀƢȀ 229 230ȀƢȀchronic care integration for endemic non-communicable diseases
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Chapter 9!References
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K1' Y)9A8'G?C'S$%$-4#)*'I;C'!"$5%&:&'URC'Y$:34%P$%'G`C'Y#44%'LS>'H84'8)A8' 3"%549'&6'%84":$#)+'84$%#'5)*4$*4'6&"95'&9'$"#&-*7')9'[)D)>'S$%5)&.'c&"9A' J11gh/gWZJ2d> K/' G$$%'ILC'!4%%)&*'`RC';&*4'I(C'4#'$.>'G%4@$.49+4'&6';84":$#)+',4$%#'()*4$*4')9' S8).5%49'$95'c&"9A'L5".#*')9'`)+$%$A"$>'L:'I'S$%5)&.'J1/1h/10W/g1d2/K> KJ ǡǡǤ ϐǣ %4#%&*-4+#)@4'*#"57>'U$*#'L6%'R45'I'/ddZh]BW]/K2Z> KB' R$7&*)'!C';&34%#*&9'MC'\&.:)9P'IC'4#'$.>'H84'(%$P49*34%A'54+.$%$#)&9'&9'#84' +&9#%&.'&6'%84":$#)+'64@4%'$95'%84":$#)+'84$%#'5)*4$*4')9'L6%)+$>'Y'L6%'R45'I' J11ZhdZWJKZ> KK ǡǡϐǡǤ 37'4+8&+$%5)&A%$-87>'H84')9$54O"O"$+7'&6'_&%.5',4$.#8'bA$9)^$#)&9' +%)#4%)$'6&%'&-#):)^)9A'#84'5)$A9&*)*'&6'*"3+.)9)+$.'5)*4$*4>'S)%+".$#)&9' J11dh/J1WZZB2ZZg> K0 ǡϐǡ Ǥ 6&%'%84":$#)+'84$%#'5)*4$*4'*+%449)9A>'`$#'S.)9'G%$+#'S$%5)&@$*+'R45' J11gh0WU/2B> chapter 10 Chronic Respiratory Disease
10.1 The Burden of Chronic Respiratory Disease in Rural Rwanda H84':$)9'6&%:*'&6'+8%&9)+'%4*-)%$#&%7'5)*4$*4'VS;(X')9';<$95$'$%4' $*#8:$C'+8%&9)+'&3*#%"+#)@4'-".:&9$%7'5)*4$*4'VSbG(XC'$95'3%&9+8)4+2 #$*)*>'S8%&9)+'+$%4'+.)9)+*')9'#8%44';<$95$9'5)*#%)+#*'*"--&%#':&%4'#8$9' 011'-$#)49#*'<)#8'S;(C':&*#'&6'<8&:'$%4'6&..&<45'$#'#84'84$.#8'+49#4%' [email protected]':&*#.7'6&%'$*#8:$>'G%)&%'#&'#%4$#:49#C'#84*4'-$#)49#*'+&:-.$)945' &6'34)9A'.):)#45')9'#84)%'$3).)#7'#&'+$%%7'&"#'6$%:)9A'&%'T%'+8&%4*'#8$#' $%4'@)#$.'#&'$'*"++4**6".'%"%$.'4E)*#49+4>'L+"#4'4E$+4%3$#)&9*'&6'$*#8:$' ϐ Ǥ 9&'5$#$'$@$).$3.4'%4A$%5)9A'-&-".$#)&9'-%4@$.49+4'&6'S;(')9'%"%$.';<$95$>
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?9'&"%':&54.C':&*#'+8%&9)+'%4*-)%$#&%7'5)*4$*4':$9$A4:49#'<)..'#$P4' -.$+4'$#'#84'.4@4.'&6'#84'84$.#8'+49#4%')9#4A%$#45'+8%&9)+'+$%4'+.)9)+>' H84*4'+.)9)+*'$.*&'*44'-$#)49#*'<)#8'$'@$%)4#7'&6'+8%&9)+')..94**4*'<)#8' %4.$#)@4.7'*):-.4'#%4$#:49#'$.A&%)#8:*C'*"+8'$*':&*#'+$*4*'&6'87-4%#492 *)&9C'4-).4-*7C'9&92)9*".)9'54-49549#'5)$34#4*C'#"34%+".&*)*C'$95',?\>' 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
1. Position (sit upright/leaning forward) Respiratory rate ≥ 30/min 2. If wheezing, give salbutamol 2 sprays every 15 min by Initial evaluation: metered dose inhaler with spacer Chronic cough or AND wheezing OR YES 3. If known heart disease and uncomfortable lying down, shortness of breath Patient acutely short of breath OR (≥ 3 weeks) Not able to walk unaided OR give furosemide (refer to acute decompensated heart Fever ≥ 39 failure protocol) 4. Refer urgently to district hospital
NO
Serotest in past NO Perform HIV test year?
YES
1. Treat with antibiotics (Adult dosing: doxycycline 100 mg 2x/day x 14 days Fever, chills, or amoxicillin 500 mg 3x/day productive YES cough or HIV+ x 14 days) 2. If wheezing, salbutamol inhaler 3. Have return in 1–2 weeks
Cause of dyspnea Improvement? YES was likely NO pneumonia
NO
1. Obtain CXR 2. Obtain sputum smear x 3
Leg swelling, Refer to district hospital NCD clinic for orthopnea, known YES heart condition, confirmation of suspected heart failure murmur
NO
Conjunctival 1. Check hemoglobin if available pallor, post- 2. Start elemental iron, Adults: 60 mg 2x/day, partum or other YES history of Children ≤ 40 kg: 2–3 mg/kg 1x/day bleeding 3. Albendazole 400 mg 2x/day x 7 days
NO
Wheezing, night Refer to health center integrated cough, worsened YES chonic care clinic for probable by climate change asthma or COPD (see Protocol 10.2) or exercise 238ȀƢȀchronic care integration for endemic non-communicable diseases
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TABLE 10.1 Evaluation of Asthma Attack Severity (Adapted from IUATLD Guidelines)19
Symptoms Mild asthma Moderate asthma Severe asthma Imminent attack attack attack respiratory failure Dyspnea With physical With speaking All the time All the time exertion
Can speak in Full sentences Phrases Words Unable to speak
Mental status Normal Normal or Agitated Somnolent or agitated confused
Respiratory rate Normal to fast Fast Very fast (η30 Very fast (η30 breaths/min) breaths/min)
Pulse ζ 100 100–120 η120 Bradycardic
Peak expiratory flow η 70% 50%–70% ζ 50% or ζ 100 Cannot measure (PEF) after salbutamol liters/min (% of patient’s best PEF or predicted PEF)
10.2.3 Exclusion of Causes Other Than Asthma and COPD ?9'#84'%"%$.'84$.#8'+49#4%'+.)9)+C'.$+P'&6'5)$A9&*#)+'#&&.*'$95'8)A8'-%4@$2 .49+4'&6')964+#)&"*'%4*-)%$#&%7'5)*4$*4'94+4**)#$#4'4E+."*)&9'&6'T%' 5)*4$*4*'346&%4':$P)9A'#84'5)$A9&*)*'&6'SbG('&%'$*#8:$>'[&%'#84':&*#' -$%#C'#8)*'+$9'34'5&94'37'#$P)9A'$'+$%46".'8)*#&%7'&6'*7:-#&:*>'S4%2 #$)9'*7:-#&:*'*8&".5'-%&:-#'6"%#84%'#4*#)9A>'TABLE 10.2'&"#.)94*'#84' +&::&9'+$"*4*'&6'+8%&9)+'%4*-)%$#&%7'*7:-#&:*'V.$*#)9A':&%4'#8$9'B' <44P*X'*449'$#'&"%'+.)9)+*> chapter!10 | chronic respiratory disease 239
TABLE 10.2 Causes of Chronic Dyspnea or Chronic Cough (η 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 Edema, ascites heart failure 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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PROTOCOL 10.2 Initial Management of Asthma or COPD at Integrated Chronic Care Clinics
1. Position (sit upright/leaning forward) Patient referred to 2. Give salbutamol 2 sprays every 15 min by metered dose inhaler health center 1. Patient acutely short of using a spacer chronic care clinic breath and wheezing OR YES 3. If has productive cough or fever, give dose of doxycycline 100 mg (CCC) for suspected 2. RR ≥ 30 bpm or amoxicillin 500 mg (adult dosing) asthma or COPD 4. Give dose of prednisolone 2 mg/ kg (max 60 mg) 5. Refer urgently to district hospital NO
Complete history and physical exam, including peak flow measurement
Patient 1. Consider alternative diagnosis, including with typical hyperventilation/somatization asthma symptoms, 2. May give trial of salbutamol abnormal peak flow NO or wheezing on 3. Follow up in health center CCC exam? 2 weeks–2 months for reassessment
YES 1. Start appropriate asthma treatment (see Table 10.6) and give inhaler teaching Assess asthma Patient with 2. Albendazole 400 mg 2x/day x 7 days if not severity severe YES treated within the last year (adults) (see Table 10.4) asthma or 3. Obtain sputum smear x 3 COPD 4. Refer to district hospital NCD clinic for CXR, echocardiography and higher-level evaluation
NO
1. Start appropriate asthma treatment (see Table 10.6 ) and give inhaler teaching 2. Abendazole 400 mg 2x/day x 3 days if not treated within the last year 3. Education about avoidance of triggers 4. Follow-up in health center CCC 2 weeks 5. Obtain CXR within next 6 months
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 Nonproductive Nighttime Chest tightness Reduced PEF in setting of symptoms, 20% improvement with bronchodilators 242ȀƢȀchronic care integration for endemic non-communicable diseases
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TABLE 10.4 Classification of Asthma Severity at Initial Visit26
Components of severity Intermittent Persistent
Mild Moderate Severe
Impairment Symptoms ζ 2 days/week η 2 days/week Daily Throughout but not daily the day
Nighttime awakenings None 1–2x/month 3–4x/month η 1x/week
Salbutamol use for ζ 2 days/week η 2 days/week Daily Several times symptom control but not daily per day
Interference with None Minor Some Extremely normal activity limitation limitation limited
Risk Exacerbations requiring 0–1/year η 2 exacerbations in 6 months requiring oral oral systemic cortico- systemic corticosteroids, or η 4 wheezing steroids (prednisolone) episodes/year lasting η 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. chapter!10 | chronic respiratory disease 243
TABLE 10.5 Asthma Control Test25
Maximum score is 25 (points are 1–5 in order as below) ζ 19 means asthma may not be well controlled
In the past 4 weeks, how much of the time did 1 All of the time your asthma keep you from getting as much done 2 Most of the time at work, school, or home? 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 1 More than once a day shortness of breath? 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 1 4 or more nights a week asthma symptoms (wheezing, coughing, 2 2 or 3 nights a week shortness of breath, chest tightness or pain) wake you up at night or earlier than usual in 3 Once a week the morning? 4 Once or twice 5 Not at all During the past 4 weeks, how often have you 1 3 or more times per day used your rescue inhaler (salbutamol)? 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 1 Not controlled at all the past 4 weeks? 2 Poorly controlled 3 Somewhat controlled 4 Well controlled 5 Completely controlled b"%'$--%&$+8'5&4*'9'$*P'+.)9)+)$9*'#&'5)664%49#)$#4'34#<449'SbG(' $95'$*#8:$>'H&'5&'*&'<&".5'.)P4.7'34'):-%$+#)+$.')9'#84'%"%$.';<$95$9' +8%&9)+'+$%4'+.)9)+>';)*P'6$+#&%*'6&%'SbG(')9'&"%'*4##)9A'$%4'9'<4..' "954%*#&&5>'H&3$++&'*:&P)9AC'#84':$)9'+$"*4'&6'SbG(')9')95"*#%)$.2 )^45'%4A)&9*C')*'%4.$#)@4.7'%$%4')9';<$95$'$95C'<849'-%4*49#C')*'%$%4.7'&6' $9')9#49*)#7'&%'5"%$#)&9'.)P4.7'#&'+$"*4'SbG(>'G&**)3.4'+$"*4*'&6'SbG(C' *"+8'$*'%4-4$#45'4E-&*"%4'#&'+&&P)9A'*:&P4C'$%4'8$%5'#&'O"$9#)67>'_8).4' *-)%&:4#%7':$7'34'$@$).$3.4'$#'*&:4'5)*#%)+#'8&*-)#$.'+.)9)+*C'%4*".#*' $%4'3'466&%#254-49549#'$95'-1#)$..7':)*.4$5)9A>'["%#84%:&%4C'<4' ϐ +&95)#)&9*')9'&"%'*4##)9A>'_)#8'#84'4E+4-#)&9'&6'.&9A2$+#)9A'34#$'$A&9)*#*' 244ȀƢȀchronic care integration for endemic non-communicable diseases
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TABLE 10.6 Asthma Step Therapy
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-UP when poor control STEP-DOWN when doing well Step 1: Intermittent Yes No No No chapter!10 | chronic respiratory disease 247
TABLE 10.7 Asthma Medication Dosing
Salbutamol Beclomethasone Aminophylline Prednisone 100 mcg (inhaler) 50 and 250 mcg (inhaler) 100 mg tab 5 mg tab Always use a spacer Adults and 1–2 pu#s, 3x/day High: 300 mg 1–2 mg/kg/d in two children as needed 1500 mcg (3 pu#s 2x/d) in 3 divided doses divided doses η 30 kg (max 60 mg) Medium: x 7–10 days 1000 mcg (2 pu#s 2x/d) Note: If new CRD diagnosis, Low: first, rule out TB 500 mcg (smear x 3, CXR) (1 pu# 2x/d) Children 1–2 pu#s, 3x/day High: n/a 2 mg/kg once per 10–30 kg as needed 1000 mcg/d day x 5 days (max (always use (2 pu#s 2x/d) 60 mg) spacers) Medium: 500 mcg/d (1 pu# 2x/d) Low: 250 mcg/d (1 pu# 1x/d) Children REFER TO PHYSICIAN ζ 10 kg Very small children should use a metered-dose inhaler with a spacer, or a nebulizer if available.
10.4 Follow-Up Management of Asthma PROTOCOL 10.3'&"#.)94*'*"3*4O"49#':$9$A4:49#'&6'-$#)49#*'<)#8'$9' 4*#$3.)*845'5)$A9&*)*'&6'$*#8:$>'
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`4E#C'#84'+.)9)+)$9'*8&".5'$*P'#84'-$#)49#*'$3&"#'6%4O"49+7'&6'*7:-2 #&:*>'s"4*#)&9*'6%&:'#84'L*#8:$'S&9#%&.'H4*#'V*44'TABLE 10.5X'+$9'34' Ǥǡǡϐ -4%6&%:45>'a*)9A'#8)*'5$#$C'#84'+.)9)+)$9'*8&".5'+&9*)54%'8&<'<4..'+&92 #%&..45'#84'-$#)49#=*'*7:-#&:*'$%4'$95'54+)54'<84#84%'#84%$-7'*8&".5' 34'+&9#)9"45C')9+%4$*45C'&%'54+%4$*45>' 248 ȀƢȀ chronic careintegration for endemic non-communicable diseases PROTOCOL 10.3 1. Position (sit upright/leaning forward) 2. Give salbutamol 2 sprays every 15 min by metered dose Patient with inhaler with a spacer diagnosis of 1. Patient acutely short of asthma or breath and wheezing OR 3. If has productive cough or fever, give dose of doxycycline ≥ COPD 2. RR 30 bpm 100 mg or amoxicillin 500 mg (adult dosing) 4. Give dose of prednisolone 2 mg/kg (max 60 mg) 5. Refer urgently to hospital Follow-Up Management of Asthma or COPD COPD or Asthma of Management Follow-Up at Health-Center Level
Assess degree of On Symptom 1. Continue maximum therapy asthma control, NO maximum YES compare to last visit improvement? therapy? 2. Refer to district hospital NCD clinic (see Table 10.5)
YES NO
Step up treatment Therapy x 3 (see Table 10.6) and months follow up in 2 weeks
NO YES Step down or Continue current therapy, return in 3 months continue current therapy (see Table 10.6) chapter!10 | chronic respiratory disease 249
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Chapter 10!References
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H84'G?,'T")54'#&'S8%&9)+'S$%4'?9#4A%$#)&9'6&%'U954:)+'`S(*'k';<$95$' U5)#)&9')*'6&+"*45':$)9.7'&9'$:3".$#&%7'+$%4'-4%6&%:45'37'$5@$9+45' ǡ ϐ ǡ Ǥ ǡϐ %&.4*'&6'+&::"9)#7'84$.#8'<&%P4%*C'6$:).7'$95'+&::"9)#7':45)+)94' -87*)+)$9*C'A794+&.&A)+'9"%*4*C'-$#8&.&A)*#*C'$95':45)+$.'$95'*"%A)+$.' 256ȀƢȀchronic care integration for endemic non-communicable diseases
*-4+)$.)*#*>'!"#'#8)*'@&.":4'<)..C'<4'8&-4C'&664%'$'*#$%#)9A'-&)9#'6&%'#84' +%4$#)&9'&6'$'*7*#4:'&6'+$%4'6&%'9&92+&::"9)+$3.4'5)*4$*4*W'&94'3."4-%)9#' ϐǡǡǤ
L"<=2W+2Y"#;0#526752L!7 K$/$L$,#$4'*+E42M'#*2,0+<#$D'**$#3',$%@$%5'a9)@4%*)#7 G&(2#3'(4-$%#:49#'&6'T.&3$.',4$.#8'$95'Y&+)$.'R45)+)94C'' ,$%@$%5'R45)+$.'Y+8&&. G&2'D3'()@)*)&9'&6'T.&3$.',4$.#8'UO")#7C'!%)A8$:'$95'_&:49=*',&*-)#$.' S&26&"954%C'G$%#94%*'?9',4$.#8
[43%"$%7'J1// appendix a Essential Equipment and Medicines1,2
A.1 Essential Equipment Essential equipment Health District Referral center hospital center Automatic sphygmomanometer (blood pressure xxx machine) with pediatric, small adult, and adult cu#s, and AC adapter Glucometer with test strips and lancets xxx
Lab: Chemistry testing (point-of-care) xx
Lab: HbA1c testing (point-of-care) xx
Lab: Hemoglobin testing xxx
Lab: HIV testing xxx
Lab: PT/INR testing (point-of-care) xx
Lab: Urinalysis xxx
Monofilament xxx
Multifunction ultrasound machine (with xx abdominal, cardiac, and obstetric probes) with ultrasound gel
Nebulizer xx
Peak flow meter xxx
Scale xxx
Tape measure/ruler xxx
Water bottle spacers (for inhaler) xxx
A.2 Essential Medicines x = Currently recommended by Rwanda MOH t = 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 258ȀƢȀchronic care integration for endemic non-communicable diseases
Palliative care Pregnancy Health District Referral category center hospital 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 Pregnancy Health District Referral chronic kidney disease category center hospital center Amlodipine C t x x Aspirin C–D x x x
Atenolol D t x x Captopril D t x x Carvedilol C ttt Erythromycin B x x x
Furosemide (Lasix) C t x x Hydralazine C t x x Isosorbide dinitrate C ttx Lisinopril D ttt Magnesium sulfate A x x x
Methyldopa A ttx Nifedipine retard C ttx Penicillin G benzathine B x x x
Penicillin V B x x x
Propranolol C ttx Spironolactone (Aldactone) D ttx Warfarin X tt Pregnancy Health District Referral Diabetes category center hospital 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 260ȀƢȀchronic care integration for endemic non-communicable diseases
Pregnancy Health District Referral Chronic respiratory disease category center hospital 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
Pregnancy Health District Referral Epilepsy category center hospital 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
/' `$#)&9$.'U**49#)$.'R45)+)94*'F)*#>'0#8'U5)#)&9>'M)A$.)W'R)9)*#%7'&6',4$.#8C' ;<$95$h'J11d> 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 b Cost 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 H84'6&..&<)9A'+&*#':&54.'-%&D4+#*'#84'4*#):$#45':$%A)9$.'+&*#*'&6'9$2 #)&9$.'+8%&9)+'+$%4')9#4A%$#)&9'6&%'*4.4+#45'4954:)+'9&92+&::"9)+$3.4' Ǥ Ǧϐ 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%2 6&%:)9A'B11'*"%A4%)4*'-4%'74$%>
H84'4*#):$#45'#):4'#&':&@4'6%&:'$'*7*#4:'<)#8'/1m'`S('+8%&9)+'+$%4' +&@4%$A4'$#'5)*#%)+#'.4@4.'#&'$'*7*#4:'<)#8'/11m'+&@4%$A4'$#'#8)*'.4@4.')*' $--%&E):$#4.7'J'74$%*'3$*45'&9'+"%%49#'#%$)9)9A'$--%&$+84*>
L*'+8%&9)+'+$%4'*4%@)+4*'$%4'54+49#%$.)^45'#&'#84'84$.#82+49#4%'[email protected]' Ǧϐ ǡ +&*#*>'L#'#84'*$:4'#):4C'#84'+&"9#%7=*')9#4%9$.'*&"%+4*'&6'%4@49"4'<)..' +&9#)9"4'#&')9+%4$*4'$*'<4..> 262ȀƢȀchronic care integration for endemic non-communicable diseases
Average annual cost
Case- Population Condition finding rate prevalence. Cases found Total Per patient Per capita Cardiomyopathy 30% 0.2% 6,000 $2,009,506 $334 $0.20
Cardiac surgical 3% 0.1% 300 $3,709 $412 $0.012 follow-up
Screening and 100% 0.1% 9,000 $46,873 $5 $0.005 follow-up for HIV nephropathy Diabetes 50% 0.44% 22,000 $3,806,655 $173 $0.38
Hypertension 100% 4% 400,000 $7,632,542 $9 $0.76 (160/90 threshold)
Chronic respiratory 15% 2% 24,900 $1,453,695 $57 $0.14 disease
Epilepsy 30% 1% 30,000 $738,003 $25 $0.07
Chronic care $4,393,920 $1.57 integration subtotal Cardiac surgery 3% 0.1% 300 $1,164,000 $3,880 $0.12 (initial surgery)tt
TOTAL $4,393,920 $1.69 t Prevalence given for the entire population. tt 300 cases per year.
B.2 Cardiomyopathy B.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) $0.025 20 mg 3x/d $27.2 20 mg tablets
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 Patient Regimen Annual cost FLC: Furosemide 40 mg 2x/d, lisinopril 20 mg 1x/d, $40.25 carvedilol 25 mg 2x/d FHIC: Furosemide 40 mg 2x/d, hydralazine 50 mg 3x/d, $90.46 IDN 20 mg 3x/d, carvedilol 25 mg 2x/d 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 Capita Annual 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 Surgery B.3.1 Cost Inputs B.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 264ȀƢȀchronic 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 ϐ $*'#84'9":34%'&6'&-4%$#)&9*'-4%'74$%')9+%4$*4*>
$11,259
$8,444
$5,630
$2,815
$0 50 100 150 200 250 300 Number of Surgeries per Year
average fixed cost/patient average variable cost/patient appendix b | cost models 265
B.3.1.4 Regimen and Follow-Up Costs Annual cost Visits per year Cost per visit 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 $2.78 $33.3 12 visits
Subtotal $412
B.3.2 Population Age Distribution and Case-Finding Population 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 Nephropathy B.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 Costs Other program costs (per patient enrolled) Annual cost
Laboratory testing (point-of-care chemistries @ $9.8 x 6 visits) $58.8 266ȀƢȀchronic care integration for endemic non-communicable diseases
B.4.3 Population Age Distribution and Case-Finding Total 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 Capita Cost to screen population Cost
Urine dipstick for screening population $112.88
Creatinine for patients with proteinuria $945
Total $1,057.9
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.5 Diabetes B.5.1 Cost Inputs Price per Units/tablets Medication unit/tablet Goal regimen per day Annual cost Insulin 70/30 (mixte) $0.009 15 U 2x/d 30 $99 100 IU/mL, 10 mL
Insulin regular (rapide) $0.010 10 U 2x/d 20 $72 100 IU/mL, 10 mL
Insulin NPH (lente) $0.010 15 U 2x/d 30 $109 100 IU/mL, 10 mL
Syringes $0.088 2x/d 2 $65 (1 mL, 26 g needle)
Metformin $0.010 1000 mg 2x/d 4 $15 500 mg tablets
Glibenclamide $0.003 5 mg 2x/d 2 $2 5 mg tablets
Lisinopril $0.01 5 mg 1x/d 0.5 $2 10 mg tablets appendix b | cost models 267
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 Patient Regimen 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
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 $207 $36 $30 $20 $87 $380 insulin 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-Finding Total 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 268ȀƢȀchronic care integration for endemic non-communicable diseases
B.5.4 Total Marginal Costs Per Capita Total cost
Proportion of patients Estimated Total annual Regimen on this regimen patient load 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
B.6 Hypertension Cost Models B.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 $19.56 20 mg, atenolol 25 mg
t H = HCTZ; N = amlodipine; L = lisinopril; A = atenolol appendix b | cost models 269
Laboratory costs per Hypertension stage Projected yearly lab monitoring patient per year Stage I (140/90) Urine dipstick 1x/y, creatinine $0.17 1x/y for 5%
Stage II (η 160/100) Urine dipstick 1x/y, creatinine $0.32 1x/y for 10%
Stage III (η 180/110) Urine dipstick 1x/y, creatinine 1x/y for $0.98 20%, chemistries 5%
Hypertension Total clinic Laboratory stage Regimen. costs.. Medication testing Total costs Stage I 100% H $3 $0.59 $0.17 $3.7 (140/90)
Stage II 100% HN $6 $6.57 $0.32 $12.9 (η160/100)
Stage III 70% HNL, $18 $17.10 $0.98 $36.1 (η180/110) 30% HNLA t H = HCTZ; N = amlodipine; L = lisinopril; A = atenolol tt Clinic cost: Stage I (1 visit per year); Stage II (2 visits per year); Stage III (6 visits per year). $3/visit
B.6.3 Population Age Distribution and Case-Finding Total 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 140/90 160/100 180/110 Program costs by treatment threshold threshold threshold 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 $3.72 $9.20 $17.10 cost per patient
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). 270ȀƢȀchronic care integration for endemic non-communicable diseases
B.7 Chronic Respiratory Disease Cost Models B.7.1 Cost Inputs Price per Annual Individual medication costs unit/tablet Goal regimen cost Salbutamol 0.1 mg inhaler $0.01 200 mcg 4x/d $20
Beclomethasone 250 mcg inhaler, $0.02 500 mcg 2x/d $33 medium dose
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 Patient Asthma 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
Clinic Cost per Total clinic Total cost Asthma severity Medications visits clinic visit visit cost per patient Intermittent $20 3 $3 $9 $29
Moderate persistent $53 10 $3 $30 $83
Severe persistent $79 12 $7* $83 $211tt
t Including transportation cost. tt Includes community health worker e#ort for directly observed therapy.
B.7.3 Population Age Distribution and Case-Finding Total 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
Estimated severity Severity classification 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 appendix b | cost models 271
B.7.4 Total Marginal Costs Per Capita Total annual Total annual Severity classification medication cost 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 Epilepsy Cost Models B.8.1 Cost Inputs Price per Annual cost Medication tablet/unit Goal regimen 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.8.2 Annual Regimen Costs Per Patient Annual regimen Annual clinic Cost per Annual clinic Total annual Regimen costs (per patient) visits clinic visit visit cost cost Phenobarbital $2.12 6 $3 $18 $20 100 mg 1x/d
Carbamazepine $11.08 6 $3 $18 $29 100 mg 2x/d
B.8.3 Population Distribution and Case-Finding Catchment 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 272ȀƢȀchronic care integration for endemic non-communicable diseases
B.8.4 Total Marginal Costs Per Capita Estimated total marginal program cost $25,830
Estimated marginal per capita program cost $0.07 appendix c Indicators 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 η 200 !mol/L
Number of post-cardiac surgery patients
Interventions
In the cardiomyopathy subgroup, percent with heart rate η 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 η 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 274ȀƢȀchronic 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 276ȀƢȀchronic 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 ζ 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 η 5.0 mEq/dL)
Percent and number of patients with renal failure who have blood pressure controlled (ζ 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 η 126 mg/dL, (b) HbA1c η 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 ζ 8%
Percent and number with 3 or more hypoglycemic episodes in prior 3 months
Percent and number of patients hospitalized for diabetes 278ȀƢȀchronic 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 ζ 40 years old, number/percent without a recorded creatinine
Of patients with stage III HTN (SBP η180 or DBP η 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 ζ 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 280ȀƢȀchronic 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 282ȀƢȀchronic care integration for endemic non-communicable diseases
C.7 Epilepsy
Demographics
Percent male and female
Percent and number in age range (ζ 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 η 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 η 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 d Forms
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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)+*> 284ȀƢȀchronic care integration for endemic non-communicable diseases
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 n/a control? yes no
If no, why______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:
appendix d | forms 285
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:______
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 : 286ȀƢȀchronic care integration for endemic non-communicable diseases
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) ______FRW
Time to travel to health center ______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 : "*- 6 RR: ______SaO2: ____% Normal Abnormal cachectic obese tachypneic General well-appearing use of accessory muscles HEENT JVP normal JVP high goiter
Lungs clear crackles (If yes, location:______) wheezing
Heart PMI non-displaced tachycardia irregular rhythm PMI displaced regular rhythm murmur 1 location :______
no murmurs systolic diastolic murmur 2 location :______
systolic diastolic
Abdomen soft non-tender splenomegaly ____ cm hepatomegaly : ____ cm
no hepatomegaly pulsatile liver no splenomegaly ascites: mild moderate abundant
no ascites tenderness: RUQ LUQ RLQ LLQ
no peripheral edema cold peripheral edema 1+ 2+ 3+
Extremities no joint pain or swelling joints swollen joints
Neuro no abnormalities focal motor deficit
Other ______ appendix d | forms 287
6. Previous labs (including today) Date Results
1. ___/___/___
2. ___/___/___ Chemistries point of care 3. ___/___/___ Na: K: Cal: iCa : CO2: Urée: Créat: Glyc: Hgb: INR/ PT point of care 4. ___/___/___ INR : PT :
7. Previous studies Date Results
mild Infiltrates (location:______)
normal moderate pleural effusions small big
CXR __/__/__ cardiomegaly severe (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 288ȀƢȀchronic care integration for endemic non-communicable diseases
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: ______
Follow-up ____/____/____
D. Disposition Admit to hospital Discharge home appendix d | forms 289
D.2 Flowsheets ϐ Ǧ Ǥϐ <8).4':)9):)^)9A'-$-4%<&%P'$95'$..&<)9A'+.)9)+)$9*'#&'4$*).7'$**4**'$' ǯǤ ϐ ϐȋ Ȍ ǡ Ǥ ϐ 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
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 Cellule: ______ Name : ______Umudugudu: ______ Change in CHW yes Telephone: ______ Name :______Date: ___/___/___ patient other______If a child: Name of parent or guardian Change in address or ______telephone: yes Date: ___/___/___ Telephone:______Go to page 2 to change CARDIAC DIAGNOSIS Date of Diagnosis or Problem EF 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 290ȀƢȀchronic care integration for endemic non-communicable diseases
D.2.2 Sample Events Flowsheet
HOSPITALIZATIONS Date of Date of EMR admission discharge Hospital Reason for hospitalization ___/___/______/___/______/___/______/___/______/___/______/___/___
SOCIAL ASSISTANCE OR ASSESSMENT Type of assistance or Type of assistance or EMR Date assessment EMR Date 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) 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'-$#)49#' ϐǦ ϐ @)*)#')9'#84'*4##)9A'&6':)**)9A'84%':45)+$#)&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#%&.>
RENDEZ-VOUS/ CLINIC VISIT NYHA Missed any On birth
Date Wt BP P Class Hemodyn. meds ? Na K CO2 Cr Hgb INR control ? F/up X hyper X yes yes 90/ eu no X no 50 60 110 III hypo N/A 133 4 24 130 11 N/A N/A 2/9/10 2/2/10 Comments :
hyper X yes X yes
100/ X eu no no 45 70 80 II hypo N/A N/A 2/16/10 2/9/10 Comments : ǡ ϐ 6&%'*&:4'&6'#84'T%'5)*4$*4*'6&..&<45')9'#84'+.)9)+*>
D.2.3.1 Asthma
CLINIC VISITS Activity # times/week Good Asthma limitation due awoken by # puffs/week Peak inhaler classification to shortness of
Date dyspnea of salbutamol Flow technique not asthma breath Plan and Follow-up well- daily or RDV ___/___/___
yes controlled almost daily group class :
no moderately several times ___/___/___
______times ______puffs brief controlled per week step up treatment
coaching poorly less than continue the same given controlled once per week treatment
not at all step down Comment : treatment
D.2.3.2 Diabetes
CLINIC VISITS
Date Weight BP Pulse Proteinuria Na K CO2 Cr Missed insulin ?
yes no N/A Glucose: Glucose today :______fasting
Sx of low blood yes no When?: morning afternoon evening sugar ? Comments 292ȀƢȀchronic care integration for endemic non-communicable diseases
D.2.3.3 Post-Cardiac Surgery
CLINIC VISIT Missed NYHA Volume any On birth
Date Wt BP P Class Status meds ? Na K Cr Hgb INR control ? F/up
hyper yes yes eu no no
hypo NA NA Comments : D.2.3.4 Hypertension
CLINIC VISIT Date Weight BP Pulse Proteinuria Na K Cr F/up
Comments
D.2.3.5 Epilepsy
CLINIC VISIT Number of Missed EMR Date seizures medications Side effects If female: Plan On birth control:
______seizures yes no No change yes yes Pregnant None no no Change in médications Only with illness, Allaitement/nursing Labo/Labs EEG CT alcohol yes no __/__/__ Comments:
RDV __/__/__
Clinicians
D.2.3.6 Medication Flowsheet ϐǤ +.)9)+$.')95)+$#&%*'*844#C'#8)*'$..&<*'+.)9)+)$9*'#&'*44'$#'$'A.$9+4'3' <8)+8':45)+$#)&9*'#84'-$#)49#')*'&9'$95'<8$#'+8$9A4*'8$@4'3449':$54' %4+49#.7>'H8)*')*'-$%#)+".$%.7'84.-6".'6&%'6&..&<)9A'-$#)49#*'<)#8'5)*4$*4*' *"+8'$*'84$%#'6$)."%4C'<8)+8'%4O")%4'6%4O"49#'5&*4'$5D"*#:49#*>
MEDICATION LIST Stop Medication Dose Frequency Start date date Reason for stopping __/__/__ __/__/__ __/__/__ __/__/__ __/__/__ __/__/__ __/__/__ __/__/__ appendix d | forms 293
D.2.4 Palliative Care Flowsheet ϐ ǯ ϐ &"#'$#'#84'5)*+%4#)&9'&6'#84'+.)9)+)$9C'54-495)9A'&9'#84'*4@4%)#7'&6'#84' -$#)49#=*'5)*4$*4>'H84'O"4*#)&9*'$%4'3$*45'&9'#84'L6%)+$9'G$..)$#)@4'S$%4' L**&+$#)&9=*'G$..)$#)@4'S$%4'b"#+&:4*'*+$.4C'<8)+8'8$*'3449'@$.)5$#45')9' %"%$.'*"32Y$8$%$9'L6%)+$9'+&::"9)#)4*>/
ASSESSMENT OF SYMPTOM MANAGEMENT (To be done at intake and as needed thereafter) Ask the following questions with regard to the last 3 days Have the patient rate their answer on a scale of 0 (none or not at all) to 5 (a lot or all the time). Date __/__/__ __/__/__ __/__/__ __/__/__ 1. Rate your pain 2a. Have any other symptoms been affecting how you feel? 2b. If so, please rate each symptom: Dyspnea Nausea or vomiting Constipation Diarrhea Incontinence Pruritus Fever Weakness Insomnia Foul Odor 3. Have you been feeling worried about your illness? 4. Have you been able to share how you are feeling with your family or friends? 5. Have you felt life was worthwhile? 6. Have you felt at peace? 7. Have you had enough help and advice for your family to plan for the future? If family is present: 8. How much information have you and your family been given? 9. How confident has the family felt caring for the patient? 10. Has the family been feeling worried about the patient? 294ȀƢȀchronic care integration for endemic non-communicable diseases
Appendix D!References
/' ,$%5)9A';C'Y4.:$9'FC'LA"-)&'TC'4#'$.>'\$.)5$#)&9'&6'$'+&%4'&"#+&:4':4$*"%4' 6&%'-$..)$#)@4'+$%4')9'L6%)+$W'#84'LGSL'L6%)+$9'-$..)$#)@4'&"#+&:4'*+$.4>' ,4$.#8's"$.'F)64'b"#+&:4*'J1/1hgW/1> Chronic Care Integration for Endemic Non-Communicable Diseases Non-Communicable Endemic for Integration Care Chronic the pih guide to the pih guide to Chronic Care Integration for Endemic Non-Communicable Diseases
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.
rwanda edition More information on Partners In Health can be found s66666 s66666 at our web site: www.pih.org
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