From the Guidelines
The most important evidence-based cardiac medications to prioritize for this 91-year-old patient with right-sided heart failure, pulmonary hypertension, and recurrent hypovolemia/AKIs are spironolactone and dapagliflozin, which should be reintroduced cautiously after addressing the hypovolemia. Given the patient's complex cardiac history and current presentation, careful consideration of medication management is crucial to balance the benefits of therapy with the risks, particularly in the context of recurrent hypovolemia and AKIs. The patient's medications should be adjusted as follows:
- Spironolactone should be started at a low dose (12.5-25mg daily) as it provides mortality benefit in heart failure while managing fluid retention 1.
- Dapagliflozin (10mg daily) should be added next as it has demonstrated significant benefits in heart failure with preserved ejection fraction, which is relevant given the patient's preserved EF of 55-65% 1.
- Ramipril should be reintroduced at a low dose (1.25-2.5mg daily) once renal function stabilizes, considering its importance in managing heart failure and hypertension 1.
- Metoprolol should be used cautiously at the lowest effective dose, given its potential to worsen heart failure in the setting of hypovolemia or hypoperfusion 1.
- Digoxin could be temporarily held due to its narrow therapeutic window and risk of toxicity with renal dysfunction, especially considering the patient's recurrent AKIs 1.
- Apixaban should be continued for atrial fibrillation but with close monitoring of renal function, as anticoagulation is crucial in this context but must be balanced with the risk of bleeding and renal impairment 1. Careful fluid management is essential, aiming for euvolemia while avoiding overdiuresis, and regular monitoring of electrolytes, renal function, and volume status is crucial, with medication doses adjusted based on these parameters 1. This approach is guided by the principles outlined in the ACC/AHA guidelines for the management of heart failure, emphasizing the importance of evidence-based therapy tailored to the individual patient's needs and clinical context 1.
From the Research
Medication Re-Introduction for Right-Sided Heart Failure & Pulmonary Hypertension
The patient's complex cardiac history, including paroxysmal supraventricular tachycardia/atrial fibrillation, DDD pacemaker for sinus bradycardia, right-sided heart failure, and pulmonary hypertension, requires careful consideration of evidence-based cardiac medications. Given the patient's poor fluid oral intake, recurrent AKIs, and hypovolemia, the following medications may be important to re-introduce:
- Sodium-glucose co-transporter 2 inhibitors (SGLT2i): Dapagliflozin, which the patient is already on, has been shown to reduce the risk of HF hospitalization and cardiovascular death in HF patients regardless of left ventricular ejection fraction (LVEF) and diabetes status 2.
- Guideline-directed medical therapy (GDMT): Rapid up-titration of GDMT in patients hospitalized with HF is safe and results in improved clinical outcomes 2.
- Mineralocorticoid receptor antagonists: Spironolactone, which the patient is already on, is an important component of GDMT for HF 2.
- Evidence-based beta-blockers: Metoprolol, which the patient is already on, is an important component of GDMT for HF 2.
Considerations for Medication Management
When re-introducing medications, it is essential to consider the patient's fluid status, preload, and afterload, as well as the potential for interactions with other medications 3. Additionally, the patient's renal function and risk of AKI should be closely monitored, as certain medications may exacerbate renal dysfunction 4, 5.
Potential Benefits and Risks
Re-introducing these medications may help improve the patient's symptoms and reduce the risk of HF hospitalization and cardiovascular death. However, it is crucial to carefully weigh the potential benefits and risks, considering the patient's complex medical history and comorbidities 6, 2.