What are the recommendations for optimization or modification in a 73-year-old male with Heart Failure with Reduced Ejection Fraction (HFrEF) (Ejection Fraction 45%, Status Post Cardiac Resynchronization Therapy-Defibrillator (CRT-D)), Atrial Fibrillation (A-Fib) (Status Post Atrioventricular Node (AVN) ablation), Diabetes Mellitus (DM), Chronic Obstructive Pulmonary Disease (COPD) (on Home Oxygen (O2) therapy), recurrent Urinary Tract Infections (UTIs), and Obesity (Body Mass Index (BMI) 34), admitted with Acute Decompensated Heart Failure (ADHF) and significant fluid overload?

From the Guidelines

For this 73-year-old male with acute decompensated heart failure and significant fluid overload, I recommend continuing aggressive diuresis while monitoring renal function closely, and optimizing guideline-directed medical therapy (GDMT) as per the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1. The patient's current medication regimen includes furosemide, metoprolol succinate, dapagliflozin, and apixaban.

• Increase furosemide to 160mg IV twice daily or consider adding chlorthalidone 25mg daily to enhance diuresis.
• Resume spironolactone at 25mg daily once renal function stabilizes (Cr <2.5) as it is a recommended mineralocorticoid receptor antagonist (MRA) for patients with HFrEF 1.
• Continue dapagliflozin 10mg daily as it provides both diuretic and cardioprotective effects.
• Maintain metoprolol succinate at current dose but consider uptitration to 50mg daily once euvolemic and blood pressure allows, as beta blockers are recommended for patients with HFrEF 1.
• Resume Entresto at a lower dose (24/26mg twice daily) once blood pressure improves above 100 systolic, as angiotensin receptor-neprilysin inhibitors (ARNi) are recommended for patients with HFrEF 1.
• Continue current anticoagulation with apixaban and complete the antibiotic course for UTI.
• Once stabilized, obtain right heart catheterization to better assess pulmonary pressures and right heart function given the severe TR and RV dysfunction.
• Consider referral for valvular intervention assessment for severe MR and TR.
• Implement fluid restriction to 1.5L daily and daily weights. The worsening renal function likely represents cardiorenal syndrome, which should improve with successful decongestion.
• The combination of SGLT2 inhibitor, MRA, and optimized diuretics will target different mechanisms to achieve euvolemia while providing mortality benefit in HFrEF.
• According to the 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure, ACEIs have been shown to reduce mortality and morbidity in patients with HFrEF and are recommended unless contraindicated or not tolerated in all symptomatic patients 1. However, in this case, the patient is already on optimal GDMT with an ARNi, beta blocker, and SGLT2 inhibitor, which provides similar benefits to ACEIs.
• The 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation recommends control of resting heart rate using either a beta blocker or nondihydropyridine calcium channel antagonist for patients with persistent or permanent AF and compensated HF with preserved ejection fraction (HFpEF) 1. However, this patient has HFrEF, and the current beta blocker dose is appropriate.

From the FDA Drug Label

The primary objective of PARADIGM-HF was to determine whether sacubitril and valsartan, a combination of sacubitril and an RAS inhibitor (valsartan), was superior to an RAS inhibitor (enalapril) alone in reducing the risk of the combined endpoint of cardiovascular (CV) death or hospitalization for heart failure (HF) PARADIGM-HF demonstrated that sacubitril and valsartan, a combination of sacubitril and an RAS inhibitor (valsartan), was superior to and RAS inhibitor (enalapril), in reducing the risk of the combined endpoint of cardiovascular death or hospitalization for heart failure, based on a time-to-event analysis (hazard ratio [HR] 0.80; 95% confidence interval [CI], 0.73,0.87, p <0. 0001)

The patient has HFrEF (EF 45%) and is currently on Metoprolol Succinate 25 mg/d and Entresto on hold due to hypotension. Optimization or modification of the current treatment regimen could include resuming Entresto (sacubitril and valsartan) as tolerated, as it has been shown to be superior to enalapril in reducing the risk of cardiovascular death or hospitalization for heart failure in patients with HFrEF 2. Key considerations for resuming Entresto include:

• Monitoring the patient's blood pressure to ensure it is stable and not too low
• Adjusting the dose of Entresto as needed to minimize the risk of hypotension
• Continuously monitoring the patient's renal function, as indicated by the increase in Cr 1.3-> 1.9-> 2.0, to ensure that Entresto is not exacerbating any existing renal impairment.

From the Research

Optimization and Modifications for Patient Care

The patient's condition involves multiple complexities, including heart failure with reduced ejection fraction (HFrEF), atrial fibrillation (A-Fib), diabetes mellitus (DM), chronic obstructive pulmonary disease (COPD), and obesity. Given these conditions, several considerations can be made for optimization and modifications:

• Diuretic Therapy: The use of furosemide for fluid overload management is common in heart failure patients. According to 3, diuretics play a crucial role in managing heart failure, but the choice of diuretic should be guided by the patient's clinical situation and co-morbidities. The current dosage of furosemide (120 mg/bid IV) may need adjustment based on the patient's response and renal function.
• Anticoagulation Therapy: The patient is on apixaban 5 mg/d for A-Fib. Studies such as 4 suggest that apixaban has a favorable safety profile compared to other direct oral anticoagulants (DOACs) in obese patients with atrial fibrillation and heart failure. This supports the continuation of apixaban in this patient.
• Heart Failure Management: The patient's heart failure with reduced ejection fraction (HFrEF) and significant fluid overload necessitates careful management. The use of Entresto (sacubitril/valsartan) is on hold due to hypotension, but resuming it as tolerated could be beneficial, given its efficacy in HFrEF patients.
• Lifestyle Modifications: For a patient with obesity (BMI 34), lifestyle modifications including diet and exercise are crucial. Although not directly addressed in the provided studies, general recommendations for weight management and increased physical activity can help improve overall cardiovascular health and reduce the risk of further complications.
• Monitoring and Follow-Up: Close monitoring of the patient's fluid status, renal function, and electrolyte levels is essential, especially with diuretic therapy. Regular follow-up with a cardiologist and adjustments to the treatment plan as needed are vital for optimal management.

Considerations for Specific Conditions

• Atrial Fibrillation: Management of A-Fib involves anticoagulation to prevent stroke and systemic embolism. Studies like 5 highlight the importance of anticoagulation therapy in patients with A-Fib and heart failure, supporting the use of apixaban in this patient.
• Chronic Obstructive Pulmonary Disease (COPD): While not directly addressed in the provided studies, managing COPD involves optimizing lung function and preventing exacerbations, which can impact heart failure management.
• Diabetes Mellitus (DM): Good glycemic control is essential for patients with DM and heart failure. Although not specifically mentioned, medications like dapagliflozin, which the patient is taking, have been shown to benefit patients with heart failure, regardless of diabetes status.

Future Directions

• Personalized Medicine Approach: Tailoring treatment to the individual patient's needs, considering factors like renal function, blood pressure, and co-morbid conditions, is crucial.
• Multidisciplinary Care: Involving a team of healthcare professionals, including cardiologists, primary care physicians, and specialists in other relevant fields (e.g., pulmonology for COPD), can ensure comprehensive care.