What is the best management plan for an 85-year-old female with severe heart failure with reduced ejection fraction (HFrEF) due to ischemic cardiomyopathy, severe mitral regurgitation, and severe pulmonary hypertension?

Management of Severe Heart Failure in an 85-Year-Old Female with Multiple Comorbidities

The optimal management for this 85-year-old female with severe HFrEF (EF 15%), ischemic cardiomyopathy, severe mitral regurgitation, and severe pulmonary hypertension should focus on optimizing guideline-directed medical therapy (GDMT) with careful consideration of her low ejection fraction and age, while evaluating for advanced therapies.

Medical Management

First-Line Medications

1. SGLT2 Inhibitors

   • Start with dapagliflozin 10mg daily or empagliflozin 10mg daily 1
   • These should be maintained even with low blood pressure as they have minimal impact on BP 2

2. Beta-Blockers

   • Consider metoprolol succinate (starting at 12.5-25mg daily) or bisoprolol (starting at 1.25mg daily) instead of carvedilol for better tolerability 2, 1
   • Target heart rate <70 bpm if possible 2

3. Mineralocorticoid Receptor Antagonists (MRAs)

   • Start spironolactone 12.5-25mg daily or eplerenone 25mg daily 1
   • Monitor potassium and renal function closely

4. RAS Inhibitors

   • Consider low-dose sacubitril/valsartan (24/26mg twice daily) as tolerated 1, 3
   • If not tolerated, consider low-dose ACE inhibitor or ARB
   • Careful titration with close monitoring of blood pressure

Diuretic Therapy

• Loop diuretics for symptom relief and volume management
• Adjust based on congestion symptoms and tolerance

Special Considerations for This Patient

Low Blood Pressure Management

• Space out medications to reduce synergistic hypotensive effects 2
• Consider compression stockings to minimize orthostatic drops in BP 2
• If symptomatic hypotension occurs, follow this sequence for medication adjustment:
  1. Reduce RAS inhibitors first if HR >70 bpm
  2. Reduce beta-blockers if HR <60 bpm
  3. Maintain SGLT2i and MRAs if possible 2

Severe Mitral Regurgitation

• Optimize medical therapy before considering interventional options 4
• Evaluate for transcatheter edge-to-edge repair (TEER) if symptoms persist despite optimal medical therapy 2

Severe Pulmonary Hypertension

• Focus on treating the underlying heart failure as the primary approach 5
• Ensure optimal volume status through careful diuresis
• Avoid pulmonary vasodilators which are not indicated for pulmonary hypertension secondary to left heart disease 5

Advanced Therapies to Consider

Device Therapy

• Evaluate for cardiac resynchronization therapy (CRT) if QRS duration ≥150 msec with LBBB morphology 1
• Consider ICD for primary prevention if expected survival >1 year 1

Referral Considerations

• Refer to advanced heart failure team for evaluation of:
  • Persistent symptoms despite optimal medical therapy
  • Potential candidacy for advanced therapies
  • Palliative care options 2, 1

Monitoring and Follow-up

• Close follow-up every 2-4 weeks during medication titration 2, 1
• Monitor:
  • Symptoms and functional status
  • Blood pressure and heart rate
  • Renal function and electrolytes
  • Volume status with daily weight monitoring

Cautions

• Avoid NSAIDs and COX-2 inhibitors due to increased risk of worsening heart failure 1
• Avoid non-dihydropyridine calcium channel blockers (diltiazem/verapamil) 1
• Careful monitoring for hyperkalemia, especially with combination of MRAs and RAS inhibitors 1

Prognosis

• Optimization of GDMT is associated with improved outcomes even in advanced heart failure 6
• However, patients with severely reduced EF (15%) have higher mortality risk and may benefit from early palliative care discussions 2