What is the next step in management for a 47-year-old female with a history of type 2 diabetes mellitus (DM) who was recently diagnosed with heart failure, had a normal repeat brain natriuretic peptide (BNP) level, and mild leukocytosis, and was treated with a Z-pack (azithromycin), but reports no improvement in symptoms?

From the Guidelines

This 47-year-old female with type 2 diabetes mellitus who was recently diagnosed with heart failure at the ER should be started on an ACE-I, such as enalapril, and a beta-blocker, as these medications have been shown to improve symptoms and reduce mortality in patients with heart failure and diabetes 1. Given her recent diagnosis of heart failure and type 2 diabetes mellitus, it is crucial to initiate treatment with neurohormonal antagonists, including an ACE-I or ARB, a beta-blocker, and a mineralocorticoid receptor antagonist (MRA), as recommended by the European Society of Cardiology (ESC) guidelines 1. The patient's normal BNP on repeat testing raises questions about the heart failure diagnosis, and her mildly elevated white blood cell count treated with azithromycin (Z-pack) suggests a possible infectious process. I recommend discontinuing the Z-pack if the full course has been completed and obtaining a chest X-ray and ECG to better evaluate her symptoms. She should monitor her blood glucose levels closely as both heart failure and infection can worsen glycemic control. Until she sees a cardiologist, she should restrict sodium intake to less than 2 grams daily, limit fluid intake to 1.5-2 liters per day, and weigh herself daily to track fluid retention. The discrepancy between her initial heart failure diagnosis and subsequent normal BNP is concerning and requires clarification, as BNP is typically elevated in heart failure. Her persistent symptoms despite treatment indicate either an incorrect initial diagnosis, inadequate treatment, or development of a new condition requiring prompt medical attention. According to the 2016 ESC guidelines, diuretics are recommended to improve symptoms and exercise capacity in patients with signs and/or symptoms of congestion, and should be considered to reduce the risk of HF hospitalization in patients with signs and/or symptoms of congestion 1. The patient's treatment plan should be tailored to her individual needs, and she should be closely monitored for any changes in her condition. It is essential to note that the patient's type 2 diabetes mellitus should be managed concurrently with her heart failure treatment, as uncontrolled diabetes can worsen heart failure symptoms and outcomes 1. The use of ACE-I and ARBs in patients with diabetes requires surveillance of kidney function and potassium levels, as nephropathy is a frequent occurrence in these patients 1. Beta-blockers, such as metoprolol succinate, bisoprolol, or carvedilol, are recommended in heart failure and type 2 diabetes, as they have been shown to reduce mortality and hospitalizations for heart failure 1. Overall, the patient's treatment plan should prioritize her heart failure and diabetes management, with a focus on improving her symptoms, reducing her risk of hospitalization, and enhancing her quality of life.

From the Research

Patient Presentation and History

• The patient is a 47-year-old female with a past medical history (PMH) of type 2 diabetes mellitus (DM) who presented to the clinic after a recent emergency room (ER) visit four days ago.
• She was diagnosed with heart failure (HF) during the ER visit, and her repeat B-type natriuretic peptide (BNP) levels were within normal limits (wnl).
• Her white blood cell (WBC) count was mildly elevated, and she was treated with a Z-pack (azithromycin).
• Despite treatment, the patient reports not feeling any better at this time.

Heart Failure Management

• According to the study by 2, the ACE inhibitor lisinopril is effective in reducing the risk of major clinical events in patients with heart failure.
• The study found that high doses of lisinopril (32.5 to 35mg, administered once daily) demonstrated clinically important advantages over low doses (2.5 to 5mg, administered once daily) in the treatment of congestive heart failure.
• The use of ACE inhibitors, such as lisinopril, is supported by the study by 3, which highlights the importance of combining beta-blockers and ACE inhibitors in the management of cardiovascular diseases, including heart failure.

Diagnosis and Follow-up

• The study by 4 emphasizes the importance of a timely diagnosis and follow-up of heart failure patients by general practitioners.
• The study suggests that an algorithm-based approach, including medical history, anamnesis, and clinical examination, can help general practitioners in recognizing heart failure in an early stage and providing better follow-up care.
• The study by 5 highlights the importance of timely treatment initiation in heart failure patients, as any delay can be associated with worse outcomes.

Treatment Options

• The study by 6 compares the clinical outcomes of sacubitril-valsartan versus angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) among patients with heart failure and ejection fraction at or less than 60%.
• The study found that sacubitril-valsartan use was associated with lower 12-month morbidity and mortality compared to ACEI/ARB.
• The use of sacubitril-valsartan may be considered as an alternative treatment option for heart failure patients, as supported by the study by 6.