What is the likely diagnosis and treatment for a 70-year-old patient with a history of uncontrolled Hypertension (HTN), stable Coronary Artery Disease (CAD), and Diabetes, presenting with acute onset of dyspnea, orthopnea, and peripheral edema, with vital signs indicating Tachycardia, Tachypnea, and Hypertension?

From the Guidelines

The patient's likely diagnosis is acute decompensated heart failure (ADHF) with volume overload, and the treatment should focus on relieving symptoms, improving cardiac function, and managing underlying conditions. The patient's presentation with dyspnea, orthopnea, peripheral edema, tachycardia, tachypnea, and hypertension suggests ADHF with volume overload. According to the 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 1, the treatment should aim to relieve symptoms, improve cardiac function, and manage underlying conditions.

Key Components of Treatment

• IV loop diuretic (furosemide 40mg IV initially, then titrated based on response) to reduce fluid overload, as recommended by the 2009 ACCF/AHA guidelines for the diagnosis and management of heart failure in adults 1
• ACE inhibitor (lisinopril 5-10mg daily) to reduce afterload and improve cardiac function while managing hypertension, as recommended by the 2007 guidelines for the management of arterial hypertension 1
• Beta-blocker (metoprolol 12.5-25mg twice daily) to control tachycardia and provide long-term cardiac protection, as recommended by the 2007 guidelines for the management of arterial hypertension 1
• Aldosterone antagonist (spironolactone 25mg daily) to enhance diuresis and reduce mortality in heart failure, as recommended by the 2009 ACCF/AHA guidelines for the diagnosis and management of heart failure in adults 1
• Continuation of diabetes medication with careful monitoring during acute treatment, as recommended by the 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 1
• Potassium and magnesium supplements as needed based on pending electrolyte results, since diuretic therapy may cause electrolyte imbalances, as recommended by the 2009 ACCF/AHA guidelines for the diagnosis and management of heart failure in adults 1

Monitoring and Adjustments

Close monitoring of vital signs, fluid status, electrolytes, and renal function will be essential during treatment, as recommended by the 2009 ACCF/AHA guidelines for the diagnosis and management of heart failure in adults 1. The treatment regimen should be adjusted based on the patient's response to therapy, and additional medications or interventions may be necessary to manage underlying conditions or prevent complications.

From the FDA Drug Label

The primary objective of PARADIGM-HF was to determine whether sacubitril and valsartan, a combination of sacubitril and an RAS inhibitor (valsartan), was superior to an RAS inhibitor (enalapril) alone in reducing the risk of the combined endpoint of cardiovascular (CV) death or hospitalization for heart failure (HF) Patients had to have been on an ACE inhibitor or ARB for at least four weeks and on maximally tolerated doses of beta-blockers. The population was 66% Caucasian, 18% Asian, and 5% Black; the mean age was 64 years and 78% were male. At randomization, 70% of patients were NYHA Class II, 24% were NYHA Class III, and 0. 7% were NYHA Class IV. The mean left ventricular ejection fraction was 29%. The underlying cause of heart failure was coronary artery disease in 60% of patients; 71% had a history of hypertension, 43% had a history of myocardial infarction, 37% had an eGFR less than 60 mL/min/1. 73m2, and 35% had diabetes mellitus.

The likely diagnosis for the patient is Heart Failure (HF), given the symptoms of dyspnea, orthopnea, and peripheral edema, combined with a history of uncontrolled Hypertension (HTN), stable Coronary Artery Disease (CAD), and Diabetes. The treatment for this patient could be sacubitril-valsartan, as it has been shown to be superior to enalapril in reducing the risk of cardiovascular death or hospitalization for heart failure in patients with symptomatic chronic heart failure and systolic dysfunction, as demonstrated in the PARADIGM-HF trial 2. Key considerations for treatment include:

• The patient's left ventricular ejection fraction and NYHA class
• The presence of coronary artery disease, hypertension, and diabetes
• The use of beta-blockers, mineralocorticoid antagonists, and diuretics
• The potential need for hospitalization and close monitoring of the patient's condition.

From the Research

Diagnosis

The patient's symptoms of dyspnea, orthopnea, and peripheral edema, combined with vital signs indicating tachycardia, tachypnea, and hypertension, suggest a diagnosis of heart failure, likely exacerbated by uncontrolled hypertension and coronary artery disease 3, 4, 5. The patient's history of diabetes also increases the risk of cardiovascular complications.

Treatment

Treatment for this patient should focus on managing heart failure, controlling hypertension, and addressing coronary artery disease. According to the American Heart Association scientific statement, the recommended treatment for patients with heart failure and hypertension includes:

• An angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) 3, 4
• A beta-blocker 3, 4
• A diuretic, such as a thiazide or loop diuretic, to manage fluid overload 3, 4 The use of sacubitril/valsartan, an angiotensin receptor neprilysin inhibitor (ARNI), may also be considered for patients with heart failure and reduced ejection fraction 5.

Medication Management

When selecting antihypertensive medications, consideration should be given to the patient's diabetes status. ACE inhibitors or ARBs are recommended for patients with diabetes, as they have been shown to slow the progression of kidney disease 3, 4. The combination of a diuretic and a calcium channel blocker may also be effective in managing hypertension, but the risk of cardiovascular mortality should be carefully considered 6, 7.

Key Considerations

Key considerations in managing this patient's care include:

• Monitoring blood pressure and adjusting medication as needed to achieve optimal control
• Managing fluid overload and reducing symptoms of heart failure
• Addressing coronary artery disease through lifestyle modifications and medical therapy
• Carefully considering the risks and benefits of different medication combinations to minimize cardiovascular mortality 6, 7