Should a patient with peripheral edema, taking Entresto (sacubitril/valsartan) and metoprolol, with hypertension and normal estrogen levels, be referred to cardiology or can a diuretic be initiated?

Management of Peripheral Edema in a Patient on Entresto and Metoprolol

A thiazide diuretic should be initiated for this patient with peripheral edema and hypertension who is already on Entresto (sacubitril/valsartan) and metoprolol, rather than referring to cardiology first. 1

Assessment of Current Situation

• The patient presents with lower extremity edema, hypertension (148/98 mmHg), and is currently on Entresto and metoprolol, which are appropriate medications for heart failure management 1
• The patient's blood pressure is above the recommended target of <140/90 mmHg for patients with heart failure, indicating a need for additional blood pressure control 1
• Normal estrogen levels suggest that the peripheral edema is not related to hormonal factors from testosterone replacement therapy 2

Recommended Management Approach

First-Line Management: Add a Thiazide Diuretic

• Thiazide or thiazide-type diuretics (such as chlorthalidone or hydrochlorothiazide) are recommended for BP control and to reverse volume overload and associated symptoms in patients with heart failure 1
• Diuretics should be used together with an ACE inhibitor/ARB (in this case Entresto, which contains valsartan) and a beta-blocker (metoprolol) 1
• Thiazide diuretics are preferred in hypertensive heart failure patients with mild fluid retention because they confer more persistent antihypertensive effects than loop diuretics 1

Monitoring and Follow-up

• Monitor serum electrolytes, particularly potassium, as Entresto can cause hyperkalemia through its actions on the renin-angiotensin-aldosterone system 3
• Monitor renal function, as Entresto may cause decreases in renal function in susceptible individuals 3
• Follow up within 1-2 weeks to assess response to diuretic therapy by checking for improvement in edema, weight loss, and blood pressure control 1

When to Consider Cardiology Referral

• If the patient does not respond adequately to the addition of a thiazide diuretic 1
• If there are signs or symptoms suggestive of worsening heart failure (orthopnea, paroxysmal nocturnal dyspnea, unexplained cough or fatigue) in addition to the peripheral edema 1
• If there is significant worsening of renal function or development of severe hyponatremia or hyperkalemia with diuretic therapy 1

Alternative Diuretic Options

• If thiazide diuretics are ineffective, consider:
  • Adding an aldosterone receptor antagonist (spironolactone or eplerenone) if there is evidence of heart failure with reduced ejection fraction 1
  • Switching to a loop diuretic (furosemide, torsemide, or bumetanide) if there is severe heart failure (NYHA class III or IV) or severe renal impairment 1, 4
  • Using combination diuretic therapy (thiazide plus loop diuretic) for resistant edema 5

Important Considerations and Precautions

• Avoid non-dihydropyridine calcium channel blockers (verapamil, diltiazem) as they can worsen heart failure symptoms due to negative inotropic properties 1
• Be cautious with alpha-blockers like doxazosin, which should only be used if other agents for hypertension and heart failure management are inadequate 1
• Nonsteroidal anti-inflammatory drugs should be used with caution as they can worsen edema, increase blood pressure, and impair renal function 1
• If hypotension occurs after starting the diuretic, consider dose adjustment of the diuretic or other antihypertensive medications 3

By adding a thiazide diuretic to the current regimen of Entresto and metoprolol, you can effectively manage both the peripheral edema and hypertension in this patient without immediate need for cardiology referral. This approach aligns with current guidelines for heart failure management while addressing the patient's presenting symptoms.