Which medication may need to be stopped in a patient with heart failure with reduced ejection fraction (HFrEF) due to risk of hospital readmission?

Diltiazem Should Be Discontinued in JB Due to Risk of Heart Failure Exacerbation

Diltiazem should be discontinued immediately in JB due to its negative inotropic effects in heart failure with reduced ejection fraction (HFrEF), which significantly increases the risk of clinical deterioration and hospital readmission. 1

Rationale for Discontinuing Diltiazem

Contraindication in HFrEF

• Non-dihydropyridine calcium channel blockers like diltiazem have significant negative inotropic effects that can worsen heart failure symptoms in patients with reduced ejection fraction
• Recent evidence shows that diltiazem use in HFrEF patients is associated with:
  • Higher rates of clinical deterioration (33% vs 21%, p=0.044) 1
  • Increased need for inotropes and vasopressors 1
  • Higher rates of ICU transfer 1
  • Increased risk of acute kidney injury (10% vs 3.6%, p=0.002) in patients with reduced EF 2

Preferred Rate Control Options for Atrial Fibrillation in HFrEF

• Beta-blockers are the preferred first-line agents for rate control in patients with atrial fibrillation and HFrEF 3
• In OPTIMIZE-HF, discontinuation of beta-blockers was associated with higher mortality compared to those continued on beta-blockers 3
• Beta-blockers should be maintained unless there is marked volume overload or marginal cardiac output 3

Optimizing JB's Medication Regimen

Current Appropriate Medications

• Sacubitril/valsartan: Appropriate for HFrEF and should be continued 3
• Amiodarone: Appropriate for rhythm control in atrial fibrillation with HFrEF
• Apixaban: Appropriate for stroke prevention in atrial fibrillation
• Furosemide: Appropriate for volume management in HFrEF
• Metformin: Appropriate for diabetes management in HFrEF patients with eGFR >30 mL/min/1.73 m² 3

Recommended Medication Adjustments

1. Discontinue diltiazem due to increased risk of clinical deterioration in HFrEF 1
2. Optimize beta-blocker therapy for rate control of atrial fibrillation
   • Consider titrating to target doses as tolerated 3
   • Monitor heart rate and blood pressure during titration
3. Consider adding an SGLT2 inhibitor (empagliflozin, canagliflozin, or dapagliflozin)
   • Recommended in patients with T2DM and HFrEF to reduce hospitalization risk 3
   • Provides additional cardiovascular and renal protection

Monitoring After Medication Changes

• Monitor vital signs, particularly heart rate and blood pressure
• Assess for signs of volume overload or decompensation
• Check renal function and electrolytes within 1-2 weeks after medication changes
• Evaluate for symptomatic improvement in heart failure symptoms
• Regular follow-up to ensure adequate rate control of atrial fibrillation

Potential Pitfalls to Avoid

• Do not abruptly discontinue beta-blockers in stable HFrEF patients, as this is associated with increased mortality and readmission 3
• Do not undertreat heart failure with suboptimal doses of guideline-directed medical therapy, as this is associated with increased readmission rates 3
• Avoid excessive diuresis which can lead to electrolyte abnormalities and renal dysfunction
• Do not delay optimization of guideline-directed medical therapy, as delays are associated with worse outcomes 3

By discontinuing diltiazem and optimizing JB's heart failure regimen with evidence-based therapies, you can significantly reduce his risk of clinical deterioration and hospital readmission.