What is the best approach to manage a 68-year-old female's cardiovascular health with a history of HFpEF, A-fib, DM 2, OSA, anxiety, fibromyalgia, and post-COVID microvascular heart disease, presenting with shortness of breath, fatigue, and weight gain?

Management of Complex HFpEF with Atrial Fibrillation and Multiple Comorbidities

Immediate Medication Review and Optimization

The most critical action is to immediately discontinue diltiazem if this patient is on it, as non-dihydropyridine calcium channel blockers are explicitly contraindicated in heart failure patients and should be avoided due to their negative inotropic effects and potential to worsen HF symptoms. 1, 2 The American Heart Association states these agents "should be avoided" in HF patients, and the American College of Cardiology confirms their association with higher rates of worsening heart failure 2.

Rate Control Strategy for Atrial Fibrillation

For this HFpEF patient with atrial fibrillation, beta-blockers are the preferred first-line agents for rate control, not calcium channel blockers. 1, 3

• Target resting heart rate <110 bpm (lenient control) initially, with stricter control only if symptoms persist despite achieving this target 1
• If beta-blocker monotherapy is insufficient, add digoxin rather than restarting any calcium channel blocker 1, 3
• The combination of beta-blocker with digoxin is reasonable for controlling both resting and exercise heart rate, while avoiding bradycardia 1
• Amiodarone is appropriate for both rhythm and rate control in AF with HF due to minimal myocardial depression and low proarrhythmic potential 2

Addressing Tachycardia-Induced Cardiomyopathy

Given her presentation with A-fib with RVR (heart rate requiring IV medication) and severely dilated left atrium, tachycardia-induced cardiomyopathy must be considered as a contributing factor to her symptoms. 1

• Healthcare providers frequently consider rapid supraventricular arrhythmias as results of impaired ventricular function, but these rhythm disorders may actually lead to or exacerbate cardiomyopathy development 1
• For patients with AF and rapid ventricular response causing or suspected of causing tachycardia-induced cardiomyopathy, achieving rate control by either AV nodal blockade or rhythm-control strategy is reasonable 1
• If rate control cannot be achieved pharmacologically, AV node ablation with ventricular pacing is reasonable, but only after a pharmacological trial has been attempted 1

Disease-Modifying Therapy for HFpEF

Initiate an SGLT2 inhibitor (empagliflozin or dapagliflozin) immediately as first-line disease-modifying therapy for this HFpEF patient. 3

• SGLT2 inhibitors demonstrated a 21% reduction in the composite endpoint of HF hospitalization or cardiovascular death, driven primarily by a 29% reduction in HF hospitalizations 3
• These agents provide additional benefits for her diabetes management 3
• Do not delay initiation of SGLT2 inhibitors as they have proven mortality benefits 3

Additional Pharmacological Management

For her 20-pound weight gain and fluid retention, initiate or optimize loop diuretic therapy at the lowest effective dose to manage congestion and improve symptoms. 1, 3

• Diuretics are recommended in patients with HF who have evidence of fluid retention to improve symptoms 1
• Loop diuretics (furosemide 20-40 mg once or twice daily, bumetanide 0.5-1.0 mg once or twice daily, or torsemide 10-20 mg once daily) are appropriate initial choices 1
• Sodium restriction is reasonable for symptomatic HF patients to reduce congestive symptoms 1

Consider adding a mineralocorticoid receptor antagonist (spironolactone 12.5-25 mg once daily) given her severely dilated left atrium and evidence of volume overload. 1, 3

• MRAs may be particularly beneficial in patients with LVEF on the lower end of the preserved spectrum 3
• Monitor potassium and renal function closely when initiating 1

Addressing Comorbidities and Risk Factors

Obstructive Sleep Apnea Management

Ensure strict CPAP compliance as continuous positive airway pressure can increase LVEF and improve functional status in patients with HF and sleep apnea. 1

• Her reported compliance with CPAP is beneficial and should be reinforced 1
• OSA is a modifiable risk factor that can worsen both HF and AF 1

Blood Pressure Control

Optimize blood pressure control to target <130/80 mmHg using guideline-directed medical therapy. 1, 3

• Blood pressure should be controlled to prevent symptomatic HF 1
• ACE inhibitors or ARBs are reasonable for BP control in HFpEF patients 1, 3
• Maintaining optimal blood pressure is recommended in the general population to prevent AF, with ACE inhibitors or ARBs as first-line therapy 1

Weight Management

Implement a structured weight reduction program targeting at least 10% body weight loss, as she has gained 20 pounds in 2 months. 1, 3

• Weight loss is recommended as part of comprehensive risk factor management in overweight and obese individuals with AF to reduce symptoms and AF burden 1
• Maintaining normal weight (BMI 20-25 kg/m²) is recommended for the general population to prevent AF 1
• Weight reduction should be considered in obese patients to prevent AF 1

Diabetes Management

Continue metformin as it is safe in HFrEF patients with eGFR >30 mL/min/1.73 m² and may help prevent AF. 2, 1

• Metformin or SGLT2 inhibitors should be considered for individuals needing pharmacological management of diabetes to prevent AF 1
• The SGLT2 inhibitor initiated for HFpEF will provide dual benefit for both conditions 3

Post-COVID Microvascular Heart Disease Considerations

Recognize that her post-COVID microvascular heart disease may contribute to her symptoms through regional ischemia rather than global blood flow reduction. 4

• Post-COVID patients can have regional inducible ischemia and/or infarction (nearly 40% prevalence) which may suggest occult coronary disease 4
• Her nuclear stress test showing a possible defect in the proximal septum warrants follow-up, particularly given her troponin elevation during recent hospitalization 4
• Microvascular dysfunction is highly prevalent (75%) in HFpEF patients and is associated with systemic endothelial dysfunction and markers of HF severity 5

Evaluation for Rhythm Control vs. Rate Control

While rate control is generally the preferred initial strategy for HFpEF patients with AF, consider rhythm control if symptoms persist despite adequate rate control. 1, 3

• She spontaneously converted from 2:1 atrial flutter previously and was recommended for EP evaluation for possible ablation 1
• For patients with chronic HF who remain symptomatic from AF despite a rate-control strategy, it is reasonable to use a rhythm-control strategy 1
• If rhythm control is chosen, catheter ablation should be considered if antiarrhythmic therapy fails 1
• A rhythm-control strategy has not been shown to be superior to rate-control strategy in patients with HF who develop AF, but may be considered in selected patients 1

Anticoagulation Management

Ensure appropriate oral anticoagulation is continued regardless of rhythm control strategy given her elevated thromboembolic risk. 1

• Oral anticoagulation is recommended in patients with atrial flutter at elevated thromboembolic risk to prevent ischemic stroke and thromboembolism 1
• Continue OAC despite rhythm control if risk of thromboembolism exists 1

Psychosocial Support and Cardiac Rehabilitation

Address her significant psychosocial stressors (caring for elderly father and relative with Down syndrome, recent bereavement) as these can worsen both HF and AF. 1

• Patients with HF should receive specific education to facilitate HF self-care 1
• Cardiac rehabilitation can be useful in clinically stable patients with HF to improve functional capacity, exercise duration, health-related quality of life, and mortality 1
• Exercise training is recommended as safe and effective for patients with HF who are able to participate to improve functional status 1
• Maintaining an active lifestyle is recommended to prevent AF, with the equivalent of 150-300 minutes per week of moderate intensity aerobic physical activity 1

Follow-up and Monitoring Strategy

Establish close follow-up with regular re-evaluation every 6 months after presentation, then at least annually or based on clinical need. 1

• Perform focused cardiac physical exam and BNP testing monthly for the first 3 months after significant changes in therapy 1
• Monitor heart rate and blood pressure after medication adjustments, particularly after discontinuing diltiazem 2
• Assess for signs of fluid overload or worsening HF symptoms at each visit 2
• If heart rate increases above 100 bpm after stopping diltiazem, add a beta-blocker rather than restarting diltiazem 2
• Repeat echocardiography to assess response to therapy and monitor for changes in LV function, chamber sizes, and pulmonary hypertension 1

Common Pitfalls to Avoid

• Never perform AV node ablation without first attempting a pharmacological trial to achieve ventricular rate control 1, 3
• Do not use intravenous nondihydropyridine calcium channel antagonists or intravenous beta blockers in patients with decompensated HF 1
• Avoid nonsteroidal anti-inflammatory drugs as they can adversely affect clinical status in HF patients 1
• Do not delay SGLT2 inhibitor initiation 3
• Avoid binge drinking and alcohol excess as these can worsen AF 1