What is the best management approach for an elderly female patient with hypertension (HTN) and heart failure with reduced ejection fraction (HFrEF) of 40-45%, extensive atherosclerotic plaque, moderate aortic root dilation, and elevated low-density lipoprotein (LDL) levels, on metoprolol (Lopressor) and lisinopril (Zestril), with atorvastatin (Lipitor) 40 mg daily?

Optimal Management of HFrEF with Extensive CAD in an Elderly Female

This patient with HFrEF (LVEF 40-45%) requires immediate addition of an SGLT2 inhibitor (dapagliflozin 10 mg or empagliflozin 10 mg daily) to her current regimen, aggressive LDL reduction to <55 mg/dL with high-intensity statin therapy, and consideration of adding a mineralocorticoid receptor antagonist if she remains symptomatic despite optimal medical therapy. 1, 2, 3

Guideline-Directed Medical Therapy for HFrEF

First Priority: Add SGLT2 Inhibitor Immediately

• Start dapagliflozin 10 mg once daily or empagliflozin 10 mg once daily regardless of diabetes status 1, 2, 3
• SGLT2 inhibitors receive a Class 2a recommendation for patients with LVEF 41-49% (HFmrEF), with the DELIVER trial demonstrating a 21% reduction in cardiovascular death or heart failure hospitalization specifically in this LVEF range 1, 3
• The EMPEROR-Preserved trial showed empagliflozin reduced the primary composite endpoint by 21% in patients with LVEF >40%, driven by a 29% reduction in heart failure hospitalization 1
• These agents provide incremental benefit beyond fundamental neurohormonal therapy and should be added to existing medications rather than used as monotherapy 2, 3

Continue and Optimize Current Neurohormonal Blockade

• Continue metoprolol (evidence-based beta blocker for HFrEF) as it reduces all-cause and cardiovascular mortality in patients with LVEF 40-49% 1, 2
• Continue lisinopril (ACE inhibitor) which has Class I indication for HFrEF and reduces heart failure hospitalization and cardiovascular death 1, 2
• Consider switching lisinopril to sacubitril-valsartan (ARNI) if she develops recurrent symptoms or hospitalizations, as ARNI should replace ACE inhibitors to further reduce hospitalization and death risk 2

Add Mineralocorticoid Receptor Antagonist if Symptomatic

• Add spironolactone 12.5-25 mg daily if she remains symptomatic (NYHA class II-IV) despite current therapy, as MRAs have Class I indication for HFrEF with LVEF ≤35% and Class 2b for LVEF 41-49% 1, 2
• Post-hoc analysis of TOPCAT showed spironolactone reduced cardiovascular death and heart failure hospitalization in patients with LVEF 44-49% 1
• Critical caveat: Use with extreme caution—check baseline potassium and renal function, avoid if eGFR <30 mL/min or K+ >5.0 mmol/L 2

Aggressive Lipid Management for Secondary Prevention

Target LDL <55 mg/dL

• Increase atorvastatin from 40 mg to 80 mg daily to achieve LDL <55 mg/dL given her extensive atherosclerotic disease with 70-80% LAD stenosis on CT angiography 4
• The current LDL of 128 mg/dL on atorvastatin 40 mg is inadequate for secondary prevention in a patient with established coronary artery disease 4
• Recheck fasting lipid panel in 4-6 weeks after dose increase 4
• Monitor for adverse effects: Persistent transaminase elevations occur in 2.3% of patients on atorvastatin 80 mg; check liver enzymes if clinically indicated 4
• Instruct patient to report unexplained muscle pain, tenderness, or weakness, particularly if accompanied by malaise or fever, as myopathy risk increases with higher doses 4

Blood Pressure Management

Target BP <130/80 mmHg

• Current BP of 118/84 mmHg on recheck is at goal 1, 5
• Continue current doses of metoprolol and lisinopril as they provide both heart failure and blood pressure benefits 1
• The 2017 ACC/AHA guideline recommends BP lowering consistent with improved clinical outcomes in HFrEF patients, though optimal BP targets have not been proven by RCTs specifically in HF populations 1
• Avoid nondihydropyridine calcium channel blockers (verapamil, diltiazem) as they have myocardial depressant activity and worse outcomes in HF patients 1, 5

Management of Coronary Artery Disease

Medical Management is Appropriate

• Continue medical management as recommended by the interventional cardiologist given that catheterization showed less severe disease (40% proximal and mid-LAD stenosis) than suggested by CT angiography (70-80% stenosis) 1
• The discrepancy between CT angiography and invasive catheterization is common; invasive assessment is the gold standard for determining revascularization need
• Ensure aspirin therapy (if not already prescribed) for secondary prevention in this patient with established CAD

Monitoring Aortic Root Dilation

• Serial echocardiography every 1-2 years to monitor the moderately dilated aortic root (3.5 cm) 1
• Current dilation is mild and does not require intervention, but surveillance is warranted given association with hypertension
• Optimal blood pressure control helps prevent progression of aortic dilation 1

Non-Pharmacological Interventions

• Prescribe supervised exercise training program as it improves aerobic capacity and quality of life with benefits comparable to or greater than other cardiovascular conditions (Class 1 recommendation) 5
• Recommend dietary sodium restriction to <2-3 g/day to help control volume status 5
• Daily weight monitoring with instructions to report weight gain >2-3 pounds in 1-2 days, which may indicate fluid retention 1

Follow-Up Plan

• Recheck fasting lipid panel in 4-6 weeks after increasing atorvastatin to 80 mg 4
• Monitor potassium and renal function if MRA is added (baseline, at 1 week, and at 4 weeks after initiation) 2
• Reassess symptoms and volume status at each visit; adjust diuretics as needed to maintain euvolemia 5
• Continue 3-month follow-up intervals as planned, with earlier visits if symptoms worsen 1

Critical Medications to Avoid

• Never use thiazolidinediones (pioglitazone, rosiglitazone) as they cause fluid retention and worsen heart failure 5
• Avoid NSAIDs due to effects on blood pressure, volume status, and renal function 5
• Avoid nondihydropyridine calcium channel blockers (diltiazem, verapamil) due to negative inotropic effects 1, 5