What is the best treatment approach for a 73-year-old male with mildly enlarged left ventricle, grade 1 diastolic dysfunction, enlarged left atrial chamber, mitral valve regurgitation, elevated right atrial pressure, elevated B-type Natriuretic Peptide (BNP), chronic Hypertension (HTN), leg swelling, and shortness of breath?

Treatment Approach for Heart Failure with Diastolic Dysfunction and Mitral Regurgitation

The optimal treatment for this 73-year-old male with heart failure with preserved ejection fraction (HFpEF), mitral regurgitation, and hypertension should focus on optimizing blood pressure control with ACE inhibitors, adding beta-blockers, and using diuretics for symptom management. 1

Diagnosis Assessment

This patient presents with:

• Mildly enlarged left ventricle
• Grade 1 diastolic dysfunction
• Enlarged left atrial chamber
• Mitral valve regurgitation
• Elevated right atrial pressure
• Elevated BNP
• Chronic hypertension
• Symptoms: leg swelling and shortness of breath

These findings are consistent with heart failure with preserved ejection fraction (HFpEF) complicated by mitral regurgitation, likely secondary to left atrial enlargement and ventricular remodeling from chronic hypertension.

Treatment Algorithm

Step 1: Control Hypertension

• First-line therapy: ACE inhibitors to improve relaxation and cardiac distensibility 1
  • ACE inhibitors may directly improve relaxation and cardiac distensibility, promote regression of hypertrophy, and reduce hypertension
  • If not tolerated, consider an ARB such as losartan 2

Step 2: Optimize Heart Rate and Diastolic Filling

• Add beta-blocker to lower heart rate and increase diastolic filling period 1
  • This is particularly important in diastolic dysfunction to allow adequate ventricular filling

Step 3: Manage Volume Overload

• Loop diuretics (e.g., furosemide) for leg edema and dyspnea 1, 3
  • Use cautiously to avoid excessive preload reduction which could reduce stroke volume
  • Titrate based on clinical response and renal function
  • Consider adding a thiazide diuretic if response is inadequate

Step 4: Consider Additional Therapy Based on Mitral Regurgitation

• If mitral regurgitation is secondary to ventricular/atrial remodeling:
  • Continue to optimize medical therapy for heart failure 1
• If mitral regurgitation is primary (due to valve leaflet pathology):
  • Consider referral for evaluation for possible valve intervention if symptoms persist despite optimal medical therapy 1

Monitoring and Follow-up

1. Regular BNP monitoring

   • Elevated BNP is a strong predictor of cardiovascular events in patients with diastolic heart failure 4
   • BNP levels >200 pg/mL indicate higher risk and may warrant more intensive follow-up

2. Echocardiographic follow-up

   • Monitor for changes in:
     • Left ventricular size and function
     • Severity of mitral regurgitation
     • Right atrial pressure
     • Pulmonary artery pressure

3. Comprehensive heart failure management program

   • Regular clinical follow-up to assess symptoms and adjust medications
   • Heart failure education and self-monitoring strategies

Important Considerations and Pitfalls

1. Avoid excessive diuresis

   • Patients with diastolic dysfunction are preload-dependent and excessive diuresis can reduce cardiac output 1
   • Monitor for signs of hypovolemia, hypotension, and worsening renal function

2. Careful blood pressure management

   • Target adequate blood pressure control without causing hypotension
   • Systolic blood pressure <120 mmHg may compromise coronary perfusion in elderly patients

3. Atrial fibrillation risk

   • Left atrial enlargement increases risk of atrial fibrillation
   • If atrial fibrillation develops, rate control becomes crucial with beta-blockers or digoxin 1

4. Evaluation of mitral regurgitation severity

   • Determine if primary (valve pathology) or secondary (ventricular/atrial remodeling)
   • Secondary MR may improve with optimal heart failure therapy 1

5. Consider diastolic stress testing

   • If symptoms persist despite therapy, exercise echocardiography may reveal worsening diastolic function with exertion

By following this treatment approach with careful attention to blood pressure control, heart rate management, and judicious use of diuretics, most patients with diastolic dysfunction, mitral regurgitation, and hypertension can achieve significant symptom improvement and reduced risk of heart failure hospitalization.