Case 004: Heart Failure

PATIENT PRESENTATION

Chief Complaint

“I am getting more and more short of breath.”

History of Present Illness

MO is a 67-year-old female who has been getting progressively short of breath over the last 2 months. She is being referred to the emergency department by her cardiologist after an office visit.

Link to EMR

Student Work-Up

TARGETED QUESTIONS

1. What clinical presentation and diagnostic tests presented in the case are consistent with the diagnosis of heart failure?

   Hint: See Clinical Presentation and Diagnosis of Heart Failure in PPP

2. What is the patient’s New York Heart Association Functional Classification (NYHA FC) and ACC/AHA heart failure stage?

   Hint: See Heart Failure Classification and Table 7-5 in PPP

3. What is the role of angiotensin receptor-neprilysin inhibitor (ARNI) in the treatment of heart failure?

   Hint: See Angiotensin Receptor Blockers in PPP and 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure (reference 1 below)

4. What are potential benefits and precautions for the use of various intravenous vasodilators for this patient?

   Hint: See Acute and Advanced Heart Failure in PPP

5. What is the role of sodium-glucose cotransporter-2 inhibitors (SGLT2i) in the treatment of heart failure?

   Hint: See 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure (reference 1 below)

FOLLOW-UP

A repeat echocardiogram was performed one year after MO started treatment for her heart failure, and MO’s left ventricular ejection fraction (LVEF) has improved from 35% to 45%. MO is currently asymptomatic. Current HF medications include furosemide 10mg PO daily, sacubitril/valsartan 97/103mg PO BID, metoprolol succinate 100mg PO daily, spironolactone 12.5mg PO daily, and dapagliflozin 10mg PO daily.

Vital signs: T:37.4°C, BP:122/74 mmHg, P:78, RR:16, O₂sat: 98% on RA

Labs: Na 138 mEq/L, K 5.8 mEq/L, Cl 101 mEq/L, CO₂ 22 mEq/L, BUN 14 mEq/dL, SCr 0.8 mg/dL, Glu 90 mg/dL, NT-proBNP 189 ng/L

Physical exam: unremarkable

ECG: no acute ST segment changes, normal QT/QTc, no peaked T waves

MO asks if she can discontinue her heart failure medications. What is your recommendation?

Hint: See 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure (reference 1 below)

CASE SUMMARY

Global Perspective

The 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure was published after the release of the Pharmacotherapy Principles and Practice 6^th edition, and the new guideline provides additional insights to the management of heart failure. In patients with ACC/AHA Stage C heart failure with reduced ejection fraction (HFrEF), angiotensin-converting enzyme inhibitors ...