From the Guidelines
The next step for this 65-year-old male with advanced heart failure (LVEF 25-30%), elevated RV pressure, and dilated ascending aorta who refuses a Lexiscan study would be to add spironolactone 25mg daily to his medication regimen, as this aldosterone antagonist has been shown to reduce mortality in patients with severe heart failure and complements his current therapy of carvedilol, empagliflozin, and valsartan 1.
Key Considerations
- The patient's significantly reduced ejection fraction puts him at high risk for sudden cardiac death, making evaluation for an implantable cardioverter-defibrillator (ICD) crucial 1.
- A cardiology consultation to discuss advanced heart failure management options, including possible cardiac resynchronization therapy if he has a wide QRS complex on ECG, would be beneficial 1.
- A referral for an echocardiogram with strain imaging would be appropriate to better assess cardiac function and the dilated aorta without the stress component he's refusing 1.
Management Approach
- The patient should be closely monitored for signs of clinical deterioration, such as worsening edema, rising biomarkers, or evidence of progressive remodeling on imaging 1.
- The addition of spironolactone to his medication regimen should be done under close supervision, with careful monitoring of his renal function and potassium levels 1.
- Patient education on the importance of adherence to his medication regimen, monitoring for signs of deterioration, and the need for regular follow-up appointments is crucial 1.
Prioritizing Outcomes
- The primary goal of management should be to reduce morbidity and mortality, while also improving the patient's quality of life 1.
- The patient's refusal of the Lexiscan study should not preclude further evaluation and management of his heart failure, and alternative diagnostic tests should be considered if necessary 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Patient Management
The patient is a 65-year-old male with congestive heart failure, left ventricular ejection fraction (LVEF) of 25-30%, moderately elevated right ventricular (RV) systolic pressure, and dilated ascending aorta. He is already on carvedilol, Jardiance, and valsartan. Considering his refusal of the Lexiscan myocardial perfusion study for shortness of breath, the next steps could involve:
- Evaluating the potential benefits of sacubitril/valsartan, as studies such as 2 have shown its association with improved left ventricular ejection fraction and reduced risk of sudden cardiac death in patients with heart failure with reduced ejection fraction (HFrEF).
- Considering alternative diagnostic approaches, as the case in 3 where a patient with false negative regadenoson Technetium Tc99m Sestamibi stress test was later diagnosed with significant coronary artery disease using fractional flow reserve computed tomography (FFRCT).
Medication Management
Given the patient's current medication regimen, it's essential to:
- Continue carvedilol, as it has been associated with a lower risk of inappropriate implantable cardioverter-defibrillator therapy and improved outcomes in heart failure patients, as seen in 4 and 5.
- Monitor the patient's response to Jardiance and valsartan, and consider adjusting the treatment plan as needed to optimize his condition.
Further Evaluation
In light of the patient's refusal of the Lexiscan myocardial perfusion study, further evaluation could involve:
- Discussing alternative diagnostic options with the patient, such as cardiac computed tomographic angiography (CCTA) or cardiac magnetic resonance imaging (CMR), to better understand his coronary artery disease and cardiac function.
- Assessing the patient's suitability for sacubitril/valsartan therapy, considering his current medication regimen and medical history, as studies like 6 have shown its potential benefits in reducing ventricular arrhythmias and improving left ventricular function.