What is the optimal treatment plan for a 60-year-old male with Atrial Fibrillation (A-fib), Heart Failure with Reduced Ejection Fraction (HFrEF), Insulin-Dependent Diabetes Mellitus (IDDM), Hypertension, Hyperlipidemia, Hypothyroidism, and Class III Obesity?

Optimal Treatment Plan for a 60-Year-Old Male with A-fib, HFrEF, and Multiple Comorbidities

The optimal treatment plan for this patient requires immediate discontinuation of diltiazem (Cardizem) and implementation of guideline-directed medical therapy (GDMT) for HFrEF along with appropriate rate control for atrial fibrillation. 1

Immediate Medication Changes

Discontinue:

• Diltiazem (Cardizem): Must be discontinued immediately as non-dihydropyridine calcium channel blockers are contraindicated in HFrEF and increase the risk of worsening heart failure and hospitalization 1

Continue/Optimize:

1. Beta-blocker: Continue metoprolol succinate 50mg BID (target maximum tolerated dose) 1
2. ACE inhibitor: Continue lisinopril 10mg daily (titrate up as tolerated) 1
3. Diuretic: Continue furosemide 40mg daily for congestion management 1
4. Anticoagulation: Continue rivaroxaban 20mg daily with evening meal for stroke prevention (CHA₂DS₂-VASc score of 2) 1
5. Statin: Continue simvastatin 20mg daily 1

Add:

1. Mineralocorticoid Receptor Antagonist (MRA): Add spironolactone 25mg daily or eplerenone 25mg daily 1
2. SGLT2 inhibitor: Add dapagliflozin 10mg daily or empagliflozin 10mg daily 2

Rate Control Strategy for Atrial Fibrillation

• Primary rate control: Optimize metoprolol succinate dosing (target heart rate 60-100 bpm at rest) 1
• If inadequate rate control: Consider adding digoxin (especially with persistent symptoms) 1
• Avoid: Non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to increased risk of HF worsening 1

Rhythm Control Considerations

• Consider amiodarone: For this patient with HFrEF and symptomatic AF, amiodarone is the preferred antiarrhythmic if rhythm control is desired 3
• Catheter ablation: Consider only if patient remains symptomatic despite optimal medical therapy; less favorable candidate due to multiple comorbidities, obesity, and age 3

Comorbidity Management

1. Diabetes management:

   • Replace pioglitazone: Discontinue due to increased risk of fluid retention and heart failure exacerbation 4
   • Add SGLT2 inhibitor: Benefits both diabetes and heart failure 5, 2
   • Continue insulin therapy: Maintain insulin lispro via pump

2. Hypertension management:

   • Target BP <130/80 mmHg
   • Optimize ACE inhibitor (lisinopril) dosing
   • Beta-blocker (metoprolol) also contributes to BP control 1

3. Obesity management:

   • Refer to weight management program
   • Dietary sodium restriction (<2g/day)
   • Structured exercise program as tolerated 1

4. Smoking cessation:

   • High priority intervention
   • Consider pharmacotherapy (varenicline, bupropion) and behavioral support

Monitoring Plan

1. Short-term (2-4 weeks):

   • Electrolytes, renal function, and blood pressure (especially after adding MRA)
   • Heart rate control assessment
   • Volume status evaluation

2. Medium-term (3 months):

   • Echocardiography to reassess LVEF
   • Titration of GDMT to target doses
   • Evaluation of functional capacity

3. Long-term:

   • Consider ICD evaluation after 3 months of optimal medical therapy if LVEF remains ≤35% 1
   • Consider CRT if QRS duration ≥150ms with LBBB morphology 1

Common Pitfalls to Avoid

1. Continuing diltiazem: Non-dihydropyridine calcium channel blockers are contraindicated in HFrEF 1
2. Underutilization of GDMT: All four pillars (ACE-I/ARB/ARNI, beta-blocker, MRA, SGLT2i) should be implemented 2
3. Inadequate diuresis: Monitor for and treat congestion aggressively
4. Thiazolidinediones (pioglitazone): Can worsen heart failure and should be avoided 4, 5
5. Delaying ICD consideration: Should be evaluated after 3 months of optimal medical therapy if LVEF remains ≤35% 1

This comprehensive treatment plan addresses both the patient's HFrEF and atrial fibrillation while managing his multiple comorbidities, with the primary goal of reducing mortality, preventing hospitalizations, and improving quality of life.