What is the optimal management plan for a patient with reduced LVEF and elevated blood pressure presenting with severe central chest pain?

Management of a Patient with Reduced LVEF and Elevated Blood Pressure Presenting with Chest Pain

For a patient with reduced LVEF (45-55%) and elevated blood pressure (162/88 mmHg) presenting with chest pain, the optimal management includes increasing Entresto (sacubitril/valsartan) to 97-103 mg twice daily, continuing beta-blocker therapy with carvedilol, and maintaining SGLT2 inhibitor therapy with dapagliflozin.

Assessment of Current Presentation

This patient presented with:

• Severe central chest pain (8/10) with associated dyspnea, nausea, and diaphoresis
• Initial EKG showing sinus tachycardia with inferolateral ST depressions that resolved
• Negative troponin levels (ruling out acute myocardial infarction)
• Elevated BNP (386) that improved with treatment
• Echocardiogram showing reduced LVEF (45-55%) with grade 1 diastolic dysfunction
• Elevated blood pressure (162/88 mmHg) despite current therapy
• Recent coronary CT showing no evidence of coronary artery stenosis

Medication Management

1. RAAS Inhibition

• Increase Entresto from 49-51 mg to 97-103 mg twice daily to address persistent hypertension and optimize heart failure management 1
• Sacubitril/valsartan (Entresto) is indicated for patients with heart failure with reduced LVEF to reduce cardiovascular mortality and hospitalization 1
• Titrate dose every 2-4 weeks as tolerated by the patient 1

2. Beta-Blocker Therapy

• Continue carvedilol 25 mg twice daily as it is one of the three beta-blockers proven to reduce mortality in patients with reduced LVEF 2
• Beta-blockers are recommended for all stable patients with current or prior symptoms of heart failure and reduced LVEF 2
• Monitor heart rate and blood pressure during follow-up visits

3. Diuretic Therapy

• Reduce bumetanide from twice daily to once daily to protect renal function while maintaining euvolemia
• Diuretics are indicated in patients with heart failure who have evidence of fluid retention 2
• Initial daily dose of bumetanide is typically 0.5 to 1.0 mg once or twice daily 2

4. SGLT2 Inhibitor

• Continue dapagliflozin 10 mg daily as it reduces the risk of cardiovascular death and heart failure hospitalization across the LVEF spectrum 3
• SGLT2 inhibitors have demonstrated benefit in patients with heart failure regardless of previous myocardial infarction history 3, 4

5. Statin Therapy

• Continue atorvastatin 80 mg daily as high-intensity statin therapy is recommended for patients with cardiovascular disease 2
• The goal is to reduce LDL-C by at least 50% from baseline and/or achieve LDL-C <1.4 mmol/L (<55 mg/dL) 2

6. Antiplatelet Therapy

• Continue aspirin for secondary prevention
• Consider adding a P2Y12 inhibitor only if there is evidence of acute coronary syndrome, which has been ruled out in this case 2

7. Nitrates

• Provide sublingual nitroglycerin 0.4 mg as needed for anginal symptoms
• Instruct patient on proper use for chest pain episodes

Monitoring and Follow-up

1. Blood Pressure Control

   • Target blood pressure should be individualized based on tolerance
   • Schedule follow-up within 2-4 weeks to assess response to increased Entresto dose 1

2. Heart Rate Monitoring

   • Aim for heart rate control with beta-blocker therapy
   • Consider strategies to achieve heart rate <60 bpm for future coronary CTA if needed

3. Renal Function and Electrolytes

   • Monitor renal function and potassium levels, especially after increasing Entresto dose 1
   • Pay particular attention to potassium levels when using RAAS inhibitors

4. Symptom Assessment

   • Evaluate for recurrent chest pain, dyspnea, or other heart failure symptoms
   • Assess functional capacity and NYHA class at each visit

Common Pitfalls to Avoid

1. Undertreatment of Hypertension

   • Failure to adequately control blood pressure can worsen heart failure symptoms and increase cardiovascular risk
   • Don't hesitate to uptitrate medications to achieve target blood pressure

2. Inappropriate Discontinuation of GDMT

   • Avoid premature discontinuation of guideline-directed medical therapy during hospitalization or due to mild renal function changes or asymptomatic hypotension 5

3. Inadequate LVEF Assessment

   • Ensure regular echocardiographic monitoring to assess LVEF and optimize therapy accordingly 2
   • Consider reassessment of LVEF after optimization of medical therapy

4. Overlooking Non-Cardiac Causes of Symptoms

   • Address chronic back pain which may be contributing to elevated blood pressure
   • Consider other causes of chest pain given the normal coronary CT findings

By following this comprehensive management approach, you can optimize outcomes for this patient with reduced LVEF and elevated blood pressure who presented with chest pain. The focus should remain on controlling blood pressure, optimizing heart failure medications, and preventing future cardiovascular events.