From the Guidelines
At the follow-up appointment from a cardiac perspective, the physician should assess the patient's volume status, vital signs, and symptoms of heart failure, and review the effectiveness of the current diuretic regimen (torsemide 100 mg daily) and check for signs of fluid overload or dehydration, as recommended by the 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 1. The appointment should include a thorough review of the patient's medication list, particularly focusing on heart failure medications such as ACE inhibitors, ARBs, beta-blockers, or SGLT2 inhibitors, which may need to be initiated or adjusted based on the patient's renal function and clinical status, as suggested by the 2009 ACC/AHA guidelines for the diagnosis and management of heart failure in adults 1. The physician should also review the BMP results to monitor electrolytes and renal function, as diuretic therapy can cause electrolyte abnormalities. Given the patient's preserved ejection fraction heart failure, diastolic dysfunction, and cardiorenal syndrome, careful attention should be paid to optimizing blood pressure control and heart rate, as recommended by the 2005 ACC/AHA guideline update for the diagnosis and management of chronic heart failure in the adult 1. The physician should also consider ordering a repeat echocardiogram if symptoms persist or worsen, and ensure the patient has scheduled the recommended nephrology follow-up. Some key points to consider during the follow-up appointment include:
- Assessing the patient's volume status and adjusting the diuretic regimen as needed
- Reviewing the patient's medication list and adjusting heart failure medications as necessary
- Monitoring electrolytes and renal function through BMP results
- Optimizing blood pressure control and heart rate
- Considering a repeat echocardiogram if symptoms persist or worsen
- Ensuring the patient has scheduled the recommended nephrology follow-up Patient education regarding fluid restriction, daily weight monitoring, and recognition of worsening heart failure symptoms is essential for this elderly patient with complex cardiac and renal disease.
From the Research
Cardiac Perspective at Follow-up Appointment
The patient's condition involves acute congestive heart failure with preserved ejection fraction (HFpEF) and chronic kidney disease (CKD) stage 5. Considering the evidence from recent studies 2, 3, 4, the management of HFpEF, especially in patients with CKD, is complex and requires a multidisciplinary approach.
Key Considerations
- The association between CKD and HFpEF is well-established, with CKD contributing to the development of HFpEF through various mechanisms, including systemic inflammation and myocardial fibrosis 3.
- Patients with HFpEF and CKD are generally older and have more advanced disease, with CKD being a poor prognostic indicator in HFpEF 3.
- The use of sodium-glucose cotransporter 2 (SGLT2) inhibitors has shown promise in the management of HFpEF, particularly in patients with CKD, by improving renal outcomes 3, 4.
Recommendations for Follow-up Appointment
- Monitor the patient's renal function and adjust diuretic therapy as needed, considering the potential for diuretic resistance in patients with CKD 2.
- Consider the use of SGLT2 inhibitors or other novel therapeutic approaches that target both the heart and the kidney, as recommended by recent studies 3, 4.
- Emphasize the importance of a multidisciplinary approach to managing HFpEF in patients with CKD, involving close collaboration between cardiologists, nephrologists, and other healthcare professionals 4.
- Schedule regular follow-up appointments to monitor the patient's condition and adjust treatment plans as needed, taking into account the complex interplay between HFpEF and CKD 5, 6.