What is the best management approach for a 93-year-old female with Heart Failure with preserved Ejection Fraction (HFpEF), Atrial Fibrillation (AF), and a Permanent Pacemaker (PMP) with VVIR setting, who has had an episode of hyperglycemia while on metformin (metformin hydrochloride) with otherwise satisfactory glycemic control?

From the Guidelines

The best management approach for a 93-year-old female with Heart Failure with preserved Ejection Fraction (HFpEF), Atrial Fibrillation (AF), and a Permanent Pacemaker (PMP) with VVIR setting, who has had an episode of hyperglycemia while on metformin, is to continue metformin and consider adding a SGLT-2 inhibitor to her treatment regimen, as it may decrease the risk of HF hospitalization and improve glycemic control 1.

Key Considerations

• The patient's HFpEF and AF require careful management of her cardiovascular risk factors, including blood pressure control and rate control in AF.
• The use of SGLT-2 inhibitors has been shown to be beneficial in patients with HFpEF, reducing the risk of HF hospitalization and improving cardiovascular outcomes 1.
• Metformin is generally considered safe and effective in patients with HFpEF, and its use should be continued unless contraindicated 1.
• The patient's episode of hyperglycemia while on metformin may require adjustment of her glycemic treatment regimen, but metformin should still be considered the foundation of her treatment plan.

Treatment Options

• SGLT-2 inhibitors: may decrease the risk of HF hospitalization and improve glycemic control in patients with HFpEF 1.
• GLP-1 receptor agonists: may be considered in patients with HFpEF, but their use requires careful consideration of the patient's individual risk factors and comorbidities, as their efficacy and safety in HFpEF are not well established 1.
• Other antihyperglycemic agents: such as sulfonylureas, DPP-4 inhibitors, and insulin, may be considered in patients with HFpEF, but their use should be individualized based on the patient's specific needs and risk factors 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Management Approach for HFpEF

The management approach for a 93-year-old female with Heart Failure with preserved Ejection Fraction (HFpEF), Atrial Fibrillation (AF), and a Permanent Pacemaker (PMP) with VVIR setting involves several key considerations:

• Diagnosis and treatment of HFpEF, which is a complex clinical syndrome that results from any structural or functional impairment of ventricular filling or ejection of blood 2
• Identification and management of co-morbidities, such as hypertension, diabetes, and obesity, which are common in patients with HFpEF 3, 4
• Use of diuretics to manage congestive symptoms, as well as treatment of hypertension and atrial fibrillation according to evidence-based guidelines 3, 5
• Consideration of exercise and treatment by multidisciplinary teams, which may be helpful in improving functional capacity and quality of life 3, 6
• Use of sodium-glucose cotransporter type 2 inhibitors, which have been shown to reduce the risk of composite cardiovascular events in patients with HFpEF 3, 6

Treatment of Atrial Fibrillation

The treatment of atrial fibrillation in this patient involves a rate-control strategy and appropriate anticoagulation 5.

• Rate-control strategy: This involves the use of medications to control the heart rate and prevent excessive tachycardia.
• Anticoagulation: This involves the use of medications to prevent blood clots and stroke.

Management of Hyperglycemia

The management of hyperglycemia in this patient involves adjusting the metformin dose or adding other medications to control blood sugar levels.

• Metformin is commonly used to treat type 2 diabetes, but it may need to be adjusted or discontinued in patients with HFpEF who experience hyperglycemia 3
• Other medications, such as sodium-glucose cotransporter type 2 inhibitors, may be used to control blood sugar levels and reduce the risk of composite cardiovascular events in patients with HFpEF 3, 6

Permanent Pacemaker Management

The management of the permanent pacemaker with VVIR setting involves regular monitoring and adjustment as needed to ensure optimal pacing and sensing.

• VVIR setting: This setting allows the pacemaker to pace the ventricle at a rate that is determined by the patient's physical activity level.
• Regular monitoring: This involves regular checks of the pacemaker's function and adjustment of the settings as needed to ensure optimal pacing and sensing.