From the Guidelines
For this 63-year-old male with severe heart failure with reduced ejection fraction (EF 20%), recent stroke with left hemiplegia, chronic kidney disease, and current admission for palpitations and acute decompensated heart failure, I strongly recommend continuing and optimizing the current guideline-directed medical therapy (GDMT) to improve morbidity, mortality, and quality of life. The patient's current medication regimen includes carvedilol, Entresto, empagliflozin, hydralazine, isosorbide dinitrate, and furosemide, which is in line with the recommendations from the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1.
Key Recommendations:
- Increase carvedilol gradually to target dose of 25mg twice daily as tolerated, monitoring for bradycardia and hypotension.
- Optimize Entresto to target dose of 97-103mg twice daily if blood pressure allows.
- Continue empagliflozin 10mg daily as it provides both cardiovascular and renal benefits, as supported by the 2021 HFA/ESC guidelines on HF management 1.
- Maintain the hydralazine-isosorbide dinitrate combination for additional afterload reduction, especially important in this patient with CKD limiting ACE/ARB use.
- Consider adding spironolactone at a low dose (12.5mg daily) with close monitoring of potassium and renal function despite CKD, as the benefits may outweigh risks.
- Evaluate for ICD placement for primary prevention of sudden cardiac death given the severely reduced EF.
- Consider cardiac rehabilitation once stabilized to improve functional capacity.
- For the palpitations, obtain a 14-day event monitor after discharge to detect any undiagnosed arrhythmias.
- Schedule close follow-up within 7-14 days of discharge with both cardiology and nephrology.
- The patient should continue daily weight monitoring, fluid restriction (1.5-2L/day), and sodium restriction (<2g/day). These recommendations aim to reduce mortality, prevent heart failure hospitalizations, and improve quality of life by targeting neurohormonal activation, reducing cardiac workload, and optimizing hemodynamics while balancing the challenges of concurrent CKD. Some key points to consider:
- The use of SGLT2 inhibitors, such as empagliflozin, has been shown to provide cardiovascular and renal benefits in patients with HFrEF, even in those with moderate kidney dysfunction 1.
- The combination of sacubitril/valsartan, beta-blocker, MRA, and SGLT2 inhibitor may further reduce the risk of death and worsening HF compared with standard treatment 1.
- Close monitoring of the patient's condition and adjustment of the treatment plan as needed is crucial to achieve the best possible outcomes.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Evaluation and Treatment Recommendations
The patient is a 63-year-old male with Heart Failure with Reduced Ejection Fraction (HFrEF) (EF 20%), history of CVA (L-hemiplegia, 2023), and Chronic Kidney Disease (CKD). He was admitted with palpitations and Acute Decompensated Heart Failure (ADHF) but felt better after diuresis.
Current Medications and Lab Results
- The patient is currently on Furosemide 40 mg/d, Carvedilol 6.25 mg/d, Empagliflozin 10 mg/d, Entresto 24-26 mg/bid, Hydralazine 50 mg/q8h, Isordil 10 mg/q8h, ASA 81 mg/d, and Atorvastatin 80 mg/d.
- Lab results show ProBNP 20 K, HS-Trop 142-> 133, and Cr 2.3-> 1.9.
- EKG results indicate NSR 95, LVH with repol abn, and Q-wave high-lateral.
Treatment Considerations
- The use of sacubitril/valsartan, as seen in studies 2, 3, 4, has demonstrated benefits in patients with HFrEF, including reduction of mortality and disease progression, as well as improvement in cardiac remodeling and quality of life.
- However, the patient's renal dysfunction (Cr 2.3-> 1.9) may be a consideration for the use of certain medications, including Mineralocorticoid Receptor Antagonists (MRA), which the patient is not currently on due to renal dysfunction.
- Studies 5, 6 provide further insight into the efficacy and safety of sacubitril/valsartan in various populations, including those with mildly reduced or preserved ejection fraction and advanced heart failure.
Key Points for Consideration
- The patient's current medication regimen and lab results should be closely monitored to adjust treatment as necessary.
- The potential benefits and risks of sacubitril/valsartan, as well as other medications, should be considered in the context of the patient's overall clinical picture, including renal function and history of CVA.
- Multidisciplinary management and personalized treatment approaches, as suggested in study 3, may be beneficial in minimizing therapeutic inertia and managing tolerability issues.