From the Guidelines
This 63-year-old male with heart failure with reduced ejection fraction (EF 25-30%), hypertension, diabetes, and substance use disorder requires comprehensive management for acute decompensated heart failure, and I recommend proceeding with the planned left heart catheterization with Dr. Fox to evaluate coronary anatomy, as his heart failure may have an ischemic component. The current medication regimen is appropriate, including atorvastatin 20 mg daily, carvedilol 6.25 mg twice daily, dapagliflozin 10 mg daily, and spironolactone 25 mg daily. Adding an ARNI (sacubitril/valsartan) is recommended as tolerated, starting at the lowest dose (24/26 mg twice daily) and titrating up as blood pressure allows, as supported by the 2023 guidelines for heart failure management 1. Temporarily holding IV diuresis before catheterization is appropriate to prevent contrast-induced nephropathy. After catheterization, resume diuresis until euvolemic. Given his substance use (cocaine and PCP) contributing to heart failure exacerbation, addiction counseling and rehabilitation should be arranged. Close follow-up within 7-14 days after discharge is essential, with medication titration to target doses as tolerated. The patient should be educated about medication adherence, daily weight monitoring, sodium restriction, and substance cessation. His severe mitral regurgitation may require evaluation for potential intervention if symptoms persist despite optimal medical therapy, as per the European Society of Cardiology quality indicators update for the care and outcomes of adults with heart failure 1. The use of SGLT2 inhibitors, such as dapagliflozin, is also recommended for all patients with heart failure, regardless of left ventricular ejection fraction (LVEF), as they have demonstrated beneficial effects across the range of LVEF 1. The patient's treatment plan should be guided by the principles of optimal medical therapy, including the use of ACE inhibitors, ARBs, or ARNIs, beta-blockers, and MRAs, as recommended by the 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 1. Regular follow-up and monitoring of the patient's condition, including assessment of renal function, electrolyte levels, and cardiac function, are crucial to ensure optimal management of his heart failure and to prevent potential complications. By following these recommendations and guidelines, the patient's morbidity, mortality, and quality of life can be improved, and his heart failure can be effectively managed.
From the Research
Evaluation and Management Recommendations
The patient, a 63-year-old male with heart failure with reduced ejection fraction (HFrEF), hypertension, diabetes, and a history of substance abuse, was admitted with acute decompensated heart failure (ADHF) due to non-compliance with diuretics. The patient's treatment plan includes optimization of guideline-directed medical therapy (GDMT) and consideration for a left heart catheterization (LHC).
Medication Management
The patient is currently receiving:
- Atorvastatin 20 mg/d
- Carvedilol 6.25 mg/bid
- Dapagliflozin 10 mg/d
- Spironolactone 25 mg/d
- The plan is to add an angiotensin receptor-neprilysin inhibitor (ARNI) as tolerated, which is in line with the recommendations for optimal GDMT for HFrEF, as outlined in 2.
Optimization of GDMT
Studies have shown that optimization of GDMT during hospitalization can improve prognosis in patients with worsening heart failure requiring readmissions, as seen in 3. The use of a virtual, multidisciplinary GDMT team has been associated with improved heart failure therapeutic optimization, as demonstrated in 4. Additionally, treatment with beta-blockers and angiotensin receptor-neprilysin inhibitors has been shown to be associated with a lower risk of death or heart failure hospitalizations, as reported in 5.
Considerations for LHC
The decision to perform a LHC was made in consultation with Dr. Fox, and the patient is being prepared for the procedure by holding IV diuresis. The patient's EKG shows a heart rate of 114 bpm, and the TTE reveals a left ventricular ejection fraction (LVEF) of 25-30% with severe mitral regurgitation and a small to moderate pericardial effusion.
Monitoring and Follow-up
The patient's response to treatment will be closely monitored, with regular assessments of renal function, electrolyte levels, and cardiac function. The patient's urea toxicology screen remains positive for cocaine and PCP, highlighting the need for ongoing substance abuse counseling and support. As outlined in 6, the goal of GDMT is to provide significant morbidity and mortality benefits for patients with HFrEF, and careful monitoring and adjustment of medication therapy will be crucial in achieving this goal.