How to manage a 93-year-old female with elevated HbA1C, hyperglycemia, HFpEF (Heart Failure with preserved Ejection Fraction), AF (Atrial Fibrillation), on metformin (metformin hydrochloride) 500 mg bid, and with a PMP (Permanent Pacemaker) VVIR (Ventricular Pacing, Ventricular Sensing, Inhibited Response) setting?

From the Guidelines

Management of a 93-year-old female with elevated HbA1C, hyperglycemia, HFpEF, AF, on metformin 500 mg bid, and with a PMP VVIR setting should focus on optimizing glycemic control, rate control of AF, and management of HFpEF.

Glycemic Control

• The patient is already on metformin 500 mg bid, which is a suitable choice for patients with HFpEF and diabetes, as it may decrease the risk of HF hospitalization 1.
• However, given the patient's elevated HbA1C and hyperglycemia, consideration should be given to adding another agent to achieve adequate glycemic control.
• An SGLT-2 inhibitor may be a suitable option, as it may decrease the risk of HF hospitalization, but its use should be cautious in patients with renal impairment 1.

Rate Control of AF

• Beta-adrenergic blockers are the preferred agents for achieving rate control in patients with HF and AF, unless otherwise contraindicated 1.
• The patient's PMP VVIR setting may need to be adjusted to ensure adequate rate control.

Management of HFpEF

• Management of HFpEF should focus on optimizing blood pressure control, reducing volume overload, and managing comorbidities such as diabetes and AF 1.
• The patient's HFpEF management should be individualized, taking into account her age, comorbidities, and functional status.

Additional Considerations

• Anticoagulation should be considered in patients with AF and HFpEF, as it may reduce the risk of stroke and systemic embolism 1.
• Regular monitoring of the patient's renal function, electrolytes, and glycemic control is essential to adjust her medication regimen as needed.

From the FDA Drug Label

2 DOSAGE AND ADMINISTRATION

1. 1 Adult Dosage Metformin Hydrochloride Tablets The recommended starting dose of metformin hydrochloride tablets are 500 mg orally twice a day or 850 mg once a day, given with meals. Increase the dose in increments of 500 mg weekly or 850 mg every 2 weeks on the basis of glycemic control and tolerability, up to a maximum dose of 2550 mg per day, given in divided doses.

The patient is already taking metformin 500 mg bid, which is the recommended starting dose.

• The next step would be to increase the dose in increments of 500 mg weekly or 850 mg every 2 weeks, up to a maximum dose of 2550 mg per day, given in divided doses, based on glycemic control and tolerability.
• However, considering the patient's age (93 years), HFpEF, and AF, a conservative approach should be taken, and any changes to the medication regimen should be made cautiously.
• It is also important to monitor renal function and assess the benefit-risk of continuing therapy in patients with renal impairment 2.
• The patient's PMP VVIR setting and other comorbidities should also be taken into consideration when making any changes to the treatment plan.

From the Research

Management of Heart Failure with Preserved Ejection Fraction (HFpEF)

The management of a 93-year-old female with elevated HbA1C, hyperglycemia, HFpEF, AF, on metformin 500 mg bid, and with a PMP VVIR setting involves a comprehensive approach to address the various comorbidities and risk factors.

• The patient's HFpEF diagnosis requires consideration of the underlying pathophysiology, which may involve diastolic dysfunction, atrial fibrillation, and other chronic diseases such as diabetes and hypertension 3, 4, 5, 6.
• The presence of AF in patients with HFpEF is a significant concern, as it can worsen outcomes, and rhythm control may be beneficial in reducing the risk of new-onset HFpEF 7.
• The management of blood glucose levels is crucial, and conservative blood glucose control may be more beneficial than intensive control in reducing the risk of new-onset HFpEF 7.
• The use of metformin 500 mg bid may need to be reassessed, considering the patient's renal function and the potential risk of lactic acidosis, especially in the context of HFpEF 4, 5.
• The patient's PMP VVIR setting may require optimization to ensure adequate rate control and to minimize the risk of worsening HFpEF.

Pharmacologic Therapies

• Sodium-glucose cotransporter 2 inhibitors, such as dapagliflozin or empagliflozin, may be considered as first-line therapy to reduce the risk of HF hospitalization or cardiovascular death 4, 5.
• Diuretics, such as loop diuretics, may be prescribed to patients with overt congestion to improve symptoms 5.
• The use of renin-angiotensin-aldosterone blockers and angiotensin-neprilysin inhibitors may result in smaller reductions in HF hospitalizations among patients with HFpEF 4.

Non-Pharmacologic Therapies

• Exercise training and diet-induced weight loss may produce clinically meaningful increases in functional capacity and quality of life 5.
• Education in HF self-care, including adherence to medications and dietary restrictions, monitoring of symptoms and vital signs, can help avoid HF decompensation 5.