What is the best course of action for an 80+ year old patient with DM type 2, peripheral circulatory disorder, diabetic neuropathy, hypertension, CKD stage 3b, COPD, primary non-small cell carcinoma of the left lung, severe dilated cardiomyopathy, Afib with RVR, and significant dyspnea, despite medication adjustments, including hydrochlorothiazide and Trelegy Ellipta (fluticasone furoate, vilanterol, umeclidinium)?

Urgent Cardiology Referral and Guideline-Directed Heart Failure Therapy

This patient requires immediate cardiology consultation for newly diagnosed severe dilated cardiomyopathy (EF 30%) with atrial fibrillation/RVR, and initiation of guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction must take priority over polypharmacy concerns in this octogenarian with multiple comorbidities. 1

Immediate Actions

Cardiology Referral (Urgent - Within 48-72 Hours)

• Newly diagnosed severe dilated cardiomyopathy with EF 30% requires urgent specialist evaluation to determine etiology, optimize heart failure therapy, and assess need for rate/rhythm control of atrial fibrillation 2
• The combination of AFib/RVR with severe systolic dysfunction significantly increases mortality risk and requires expert management 1
• Cardiology should evaluate for potentially reversible causes of cardiomyopathy (thyroid dysfunction, tachycardia-induced cardiomyopathy from uncontrolled AFib) 3

Heart Failure Management - Prioritize Mortality Reduction

Despite this patient's age and comorbidities, guideline-directed medical therapy for HFrEF should NOT be withheld based on age alone 1. The 2022 ACC Expert Consensus emphasizes that simply "stacking" all guideline recommendations leads to polypharmacy and harm in older adults, but mortality-reducing therapies for severe HFrEF warrant prioritization 1.

Core GDMT to Initiate (in coordination with cardiology):

• Beta-blocker (if not already on one) - must be continued even during acute illness to prevent sudden cardiac death 4
• ACE inhibitor/ARB or ARNI - critical for mortality reduction in HFrEF 1
• Mineralocorticoid receptor antagonist (MRA) - reduces mortality in severe HFrEF 1
• SGLT2 inhibitor - reduces heart failure hospitalizations by 32-35% and provides mortality benefits, particularly important given concurrent diabetes 4

Diuretic Management for Recurrent Edema

• Hydrochlorothiazide is inadequate for heart failure-related volume overload 1
• Switch to loop diuretic (furosemide or torsemide) - thiazides lack sufficient efficacy in HFrEF with CKD stage 3b 1
• If loop diuretic resistance develops, consider adding back low-dose thiazide or MRA in combination 1
• Monitor renal function and electrolytes every 2-3 days initially given CKD 3b 4

Critical Pitfall: Hydrochlorothiazide was appropriately stopped for amlodipine-induced edema, but it is NOT the correct diuretic for cardiogenic edema in a patient with EF 30% and CKD 3b 1, 5

Atrial Fibrillation with RVR Management

• Rate control is essential - uncontrolled AFib can worsen or even cause dilated cardiomyopathy (tachycardia-induced cardiomyopathy) 3
• Beta-blocker is first-line for rate control in HFrEF with AFib 1
• Anticoagulation assessment is critical - patient needs stroke risk stratification (CHA2DS2-VASc) and bleeding risk assessment (HAS-BLED) given age >80, diabetes, hypertension, and heart failure 1
• Age-related changes increase both thromboembolism AND bleeding risk - requires careful shared decision-making 1

COPD Management

Dyspnea Assessment

• Distinguish cardiac vs. pulmonary dyspnea - with new severe HFrEF, dyspnea is likely multifactorial 1
• BNP or NT-proBNP levels would help differentiate (NT-proBNP ≥125 ng/L suggests HF contribution) 1
• Pulmonary function testing and assessment of COPD control should continue with pulmonologist 1

Medication Considerations

• Trelegy Ellipta is appropriate for COPD but beta-agonist component (vilanterol) may worsen tachycardia in AFib/RVR 1
• Coordinate with pulmonologist regarding potential need to adjust inhaler therapy if heart rate control remains problematic 1
• Avoid NSAIDs - can reduce diuretic efficacy and worsen heart failure 5

Left Hand Paresthesia

Likely Ulnar Nerve Distribution

• Symptoms involving ring and little finger suggest ulnar neuropathy (cubital tunnel syndrome or Guyon's canal syndrome) rather than cardiac etiology 1
• Intermittent nature lasting hours to days suggests positional compression during sleep 1
• Not an urgent cardiac symptom - can be addressed after stabilizing heart failure 1

Workup if Symptoms Persist

• Nerve conduction studies if symptoms become persistent or progressive 1
• Evaluate sleeping position and consider elbow padding at night 1
• Rule out cervical radiculopathy if distribution unclear 1

Medication Reconciliation and Deprescribing

The 2022 ACC Expert Consensus specifically warns against polypharmacy in older adults with multimorbidity 1. However, this requires prioritizing therapies based on mortality benefit rather than simply reducing pill burden 1.

Medications to Review with Cardiology:

• Current medication list needs comprehensive review - patient likely on multiple medications not mentioned 1
• Consider stopping/reducing medications with marginal benefit in context of limited life expectancy 1
• Duloxetine for diabetic neuropathy - continue as it addresses quality of life, but monitor for drug interactions with new cardiac medications 1

Monitoring Parameters During Transition

• Daily weights - >2 kg gain suggests fluid retention 4
• Renal function and electrolytes every 2-3 days initially, then weekly once stable 4
• Blood glucose 3-4 times daily during medication adjustments 4
• Signs of decompensation: increased dyspnea, orthopnea, worsening edema 4

Shared Decision-Making Framework

This patient is in a late phase of life with reduced life expectancy and multiple competing priorities 1. The ACC framework emphasizes that treatment decisions should align with patient's health priorities and goals 1.

Essential Conversation Topics:

• Goals of care - symptom management vs. longevity vs. quality of life 1
• Treatment burden - multiple medications, frequent monitoring, specialist visits 1
• Prognosis - severe HFrEF with multiple comorbidities carries significant mortality risk 1, 2
• Advanced care planning - including ICD consideration for sudden death prevention once stable 2

Common Pitfall: Age >80 does NOT automatically mean withholding evidence-based therapies, but it DOES require individualized assessment of treatment burden, life expectancy, and patient preferences 1