What is the best management plan for a patient with heart failure, COPD, and COVID-19 infection, who is on metoprolol succinate, spironolactone, rivaroxaban, and furosemide?

Cardiac Consultation Note

Assessment and Recommendations

This patient with acute-on-chronic diastolic heart failure (HFpEF), chronic atrial fibrillation, and recent COVID-19 infection requires optimization of guideline-directed medical therapy (GDMT) with careful attention to volume status, medication titration, and post-COVID cardiovascular monitoring.

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Primary Cardiac Issues

1. Acute-on-Chronic Heart Failure with Preserved Ejection Fraction (HFpEF)

Current Status:

• Admitted with decompensated HFpEF presenting with dyspnea, cardiomegaly, and mild pulmonary edema on chest imaging 1
• Markedly elevated BNP with mildly elevated troponin (nonischemic, attributed to heart failure and COVID-19 infection) 1
• Echocardiogram demonstrates preserved left ventricular systolic function with normal EF 1
• Required IV diuretics during hospitalization with transition to oral therapy 1

Current Medication Regimen:

• Furosemide 40 mg PO daily (increased from 20 mg) 2
• Spironolactone 12.5 mg PO daily (newly initiated at discharge, previously held due to low-normal BP) 3
• Metoprolol succinate 50 mg PO daily 4
• Rivaroxaban 20 mg PO daily with food (for atrial fibrillation) 1

Recommendations:

Immediate (Current Hospitalization/Post-Discharge):

• Continue current diuretic regimen with furosemide 40 mg daily and spironolactone 12.5 mg daily 1, 3
• Monitor daily weights, with instruction to contact provider if weight gain >2-3 lbs in 24 hours or >5 lbs in one week 1
• Maintain sodium restriction <2 grams daily 1
• Monitor serum electrolytes (particularly potassium), creatinine, and BUN within 1-2 weeks of discharge given diuretic adjustment and spironolactone initiation 3, 2
• Hold spironolactone if systolic BP <120 mmHg as ordered 3

Outpatient Follow-up (2-4 weeks):

• Strongly consider adding an ACE inhibitor or ARB (such as lisinopril 2.5-5 mg daily or losartan 25 mg daily) once blood pressure tolerates, as these agents should be continued in patients with heart failure and do not increase risk of COVID-19 infection or worsen outcomes 1, 5
• Initiate SGLT2 inhibitor therapy (dapagliflozin 10 mg daily or empagliflozin 10 mg daily) regardless of diabetes status, as these agents reduce heart failure hospitalizations and cardiovascular death in HFpEF 1
• The SGLT2 inhibitors have demonstrated efficacy in HFpEF independent of diabetes status and should be considered foundational therapy 1
• Titrate spironolactone to target dose of 25 mg daily as tolerated by blood pressure and renal function 3

Monitoring Parameters:

• Serum potassium should be monitored frequently (every 1-2 weeks initially) when combining spironolactone with ACE inhibitor/ARB, as hyperkalemia risk increases 3
• Renal function (creatinine, BUN) should be checked within 1-2 weeks of any medication adjustment 3, 2
• Blood pressure monitoring to ensure adequate perfusion while optimizing GDMT 1

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2. COVID-19 Infection and Cardiovascular Implications

Current Status:

• Developed fever and cough during hospitalization with positive COVID-19 test 1
• Treated with remdesivir (discontinued after 3 days due to elevated liver enzymes) 1
• Dexamethasone initiated but refused by patient 1
• Required up to 3L oxygen via nasal cannula, no significant increase from baseline 1
• Mildly elevated troponin attributed to nonischemic myocardial injury in setting of heart failure and COVID-19 1

Recommendations:

Acute Management:

• Continue all cardiovascular medications including metoprolol, spironolactone, and rivaroxaban as these do not increase risk of COVID-19 infection and should not be withdrawn 1, 5
• Beta-blockers may actually improve respiratory status in COVID-19 patients with acute respiratory distress, though must monitor for hemodynamic compromise 1
• The mildly elevated troponin without chest pain or ECG changes consistent with ACS does not require acute coronary intervention but reflects myocardial stress from heart failure and infection 1

Post-COVID Cardiovascular Monitoring:

• Schedule follow-up ECG, echocardiogram, and ambulatory rhythm monitor at 3-6 months post-infection to assess for persistent cardiac dysfunction or arrhythmias 1
• Patients with COVID-19 have increased risk of cardiovascular complications including myocardial injury, heart failure exacerbation, and dysrhythmias not only during acute phase but also beyond 30 days of infection 6
• Monitor for symptoms of post-acute COVID-19 cardiovascular sequelae including persistent dyspnea, chest pain, palpitations, or exercise intolerance 1, 6
• Consider cardiac MRI if symptoms persist or worsen, particularly if concern for myocarditis or ongoing myocardial inflammation 1

Extended Thromboprophylaxis Consideration:

• Patient is already on therapeutic anticoagulation with rivaroxaban 20 mg daily for chronic atrial fibrillation 1
• Continue rivaroxaban 20 mg daily without interruption as this provides adequate thromboprophylaxis for post-COVID thrombotic risk 1, 6
• In patients at high risk after COVID-19 hospitalization not on therapeutic anticoagulation, extended thromboprophylaxis with rivaroxaban 10 mg daily for 35 days improves outcomes, but this patient is already therapeutically anticoagulated 1, 6

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3. Chronic Atrial Fibrillation with Permanent Pacemaker

Current Status:

• Chronic atrial fibrillation on rivaroxaban 20 mg daily 1
• Permanent pacemaker in place, interrogated during hospitalization with normal function 1
• Metoprolol succinate 50 mg daily for rate control 4

Recommendations:

Anticoagulation:

• Continue rivaroxaban 20 mg daily with food for stroke prevention in atrial fibrillation 1
• Rivaroxaban should be continued during COVID-19 infection and recovery without interruption 1
• Monitor for drug interactions: lopinavir/ritonavir (if used for COVID-19 treatment) may inhibit CYP3A4 and increase rivaroxaban levels, though patient has completed COVID-19 treatment 1

Rate Control:

• Continue metoprolol succinate 50 mg daily for rate control 4
• Beta-blockers should not be withdrawn in patients with COVID-19 and may provide benefit, though monitor for bradycardia or hemodynamic compromise 1, 4
• Metoprolol can precipitate cardiogenic shock in patients with greater cardiac compromise, so monitor carefully given recent heart failure decompensation 4

Pacemaker Management:

• Pacemaker interrogation showed normal function during hospitalization 1
• Continue routine pacemaker follow-up per device clinic recommendations 1

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4. Hypertension Management

Current Status:

• History of essential hypertension 1
• Hydralazine 25 mg BID held during hospitalization due to low-normal blood pressure 1
• Current regimen: metoprolol succinate 50 mg daily, spironolactone 12.5 mg daily 3, 4

Recommendations:

Blood Pressure Optimization:

• Hold hydralazine for now given recent low-normal blood pressures and need to add ACE inhibitor/ARB 1
• Add ACE inhibitor (lisinopril 2.5-5 mg daily) or ARB (losartan 25 mg daily) once blood pressure tolerates (SBP >120 mmHg) as these are foundational therapy for heart failure and hypertension 1
• ACE inhibitors and ARBs should be continued in patients with COVID-19 and do not increase infection risk or worsen outcomes 1
• Monitor blood pressure closely with medication adjustments, particularly given spironolactone instruction to hold if SBP <120 mmHg 3

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5. Hyperlipidemia

Current Status:

• On atorvastatin 10 mg daily and ezetimibe 10 mg daily 1

Recommendations:

Lipid Management:

• Continue atorvastatin 10 mg daily and ezetimibe 10 mg daily 1
• If lopinavir/ritonavir or other protease inhibitors are used for COVID-19 treatment, atorvastatin should be administered at lowest possible dose due to CYP3A4 inhibition, though patient has completed COVID-19 treatment 1
• No changes needed to current regimen 1

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6. Type 2 Diabetes Mellitus

Current Status:

• Type 2 diabetes with HbA1c [value not provided] 1
• Currently on glipizide 20 mg daily (2 tablets of 10 mg) 1
• Sliding scale insulin held during hospitalization 1

Recommendations:

Glycemic Control:

• Continue glipizide 20 mg daily 1
• Strongly recommend adding SGLT2 inhibitor (dapagliflozin 10 mg daily or empagliflozin 10 mg daily) for dual benefit of glycemic control and heart failure management 1
• SGLT2 inhibitors reduce heart failure hospitalizations and cardiovascular death in patients with HFpEF regardless of diabetes status 1
• SGLT2 inhibitors also slow decline in kidney function, which is important given patient's history of acute cystitis and potential renal vulnerability 1
• Monitor blood glucose closely when initiating SGLT2 inhibitor and adjust glipizide dose if hypoglycemia occurs 1

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Medication Reconciliation and Safety

Critical Drug Interactions to Monitor:

1. Spironolactone + ACE inhibitor/ARB: Increased hyperkalemia risk - monitor potassium every 1-2 weeks initially 3
2. Furosemide + NSAIDs: NSAIDs may reduce natriuretic and antihypertensive effects of furosemide - avoid NSAIDs if possible 2
3. Rivaroxaban + Antiplatelet agents: Patient not on antiplatelet therapy, which is appropriate 1
4. Metoprolol + COVID-19: Beta-blockers may improve respiratory status but monitor for bradycardia and hemodynamic compromise 1, 4

Medications to Continue Without Interruption:

• All cardiovascular medications (metoprolol, spironolactone, furosemide, rivaroxaban) should be continued during and after COVID-19 infection 1, 5
• ACE inhibitors/ARBs (when added) should not be withdrawn due to COVID-19 concerns 1

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Follow-Up Plan

2 Weeks Post-Discharge:

• Check basic metabolic panel (electrolytes, creatinine, BUN) to assess for hyperkalemia and renal function 3, 2
• Check weight and volume status 1
• Assess blood pressure tolerance for ACE inhibitor/ARB initiation 1

4-6 Weeks Post-Discharge:

• Cardiology follow-up to initiate ACE inhibitor/ARB and SGLT2 inhibitor if not already started 1
• Reassess diuretic dosing based on volume status and symptoms 1
• Titrate spironolactone to 25 mg daily if tolerated 3

3-6 Months Post-COVID Infection:

• Repeat ECG, echocardiogram, and ambulatory rhythm monitor to assess for post-COVID cardiovascular sequelae 1
• Cardiac MRI if persistent symptoms or concern for myocarditis 1

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Disposition and Prognosis

Skilled Nursing Facility Placement:

• Appropriate given physical deficits, fall risk, and need for rehabilitation 1
• Ensure SNF staff are aware of cardiac medication regimen and monitoring requirements 1
• Daily weights and volume status assessment critical 1

Prognosis:

• Patient has multiple high-risk features including advanced age, heart failure, COPD, diabetes, and recent COVID-19 infection 6
• Optimization of GDMT with ACE inhibitor/ARB and SGLT2 inhibitor will improve long-term outcomes 1
• Close monitoring for post-COVID cardiovascular complications essential given increased risk in first 6 months post-infection 6

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