What is the best management plan for a 64-year-old male patient with a history of diabetes mellitus type 2, hypertension, ischemic heart disease with an ejection fraction of 25%, benign prostatic hyperplasia, and peripheral arterial disease, presenting with symptoms of heart failure exacerbation, including progressive dyspnea, orthopnea, and lower limb edema, along with left second toe gangrene and recurrent falling due to dizziness?

Management of Complex Heart Failure with Multiple Comorbidities

This patient requires immediate optimization of guideline-directed medical therapy (GDMT) for HFrEF with careful attention to volume status, infection control, and peripheral arterial disease management, prioritizing sacubitril/valsartan (Entresto) optimization, SGLT2 inhibitor continuation, and urgent vascular surgery consultation for limb-threatening gangrene. 1

Immediate Priorities

Heart Failure Optimization with Low Blood Pressure Considerations

The patient is already on Entresto (sacubitril/valsartan), which should be continued and optimized despite recurrent dizziness, as symptomatic hypotension in chronic HFrEF can usually be managed through patient education without reducing HF pharmacotherapy. 1, 2

• Assess current Entresto dose and titrate toward target 97/103 mg twice daily if not already achieved, as this provides maximum mortality benefit 2, 3
• Asymptomatic or mildly symptomatic hypotension (transient dizziness upon standing) should NOT prompt dose reduction - patients often remain compliant when educated that transient dizziness is a side effect of life-prolonging HF drugs 1, 2
• If symptomatic hypotension is problematic, first reduce diuretic doses (Salurine) in non-congested patients rather than reducing Entresto, as overdiuresis commonly causes low BP 1, 2
• Monitor BP closely but recognize that Entresto maintains efficacy even with systolic BP <110 mmHg 2

Critical Infection and Limb-Threatening Ischemia

Urgent vascular surgery consultation is mandatory for left second toe gangrene with oozing pus and near-total occlusion of left anterior tibial artery - this represents critical limb-threatening ischemia requiring revascularization consideration or amputation 1

• Continue broad-spectrum antibiotics (meropenem, linezolid) for infected gangrene - the current regimen covers MRSA and gram-negative organisms appropriately 1
• Optimize perfusion by maintaining adequate cardiac output - worsening HF directly compromises peripheral perfusion 1
• Antiplatelet therapy with aspirin and Plavix is appropriate for PAD, though dual antiplatelet therapy increases bleeding risk with infection 1

Volume Status Assessment and Diuretic Management

The presenting symptoms (progressive dyspnea, orthopnea, lower limb edema) indicate volume overload requiring aggressive diuresis, but recent dizziness/falls suggest possible overdiuresis 1, 4

• Perform daily weights, strict intake/output monitoring, and clinical assessment for jugular venous distension, pulmonary rales, and peripheral edema 1, 4
• Adjust Salurine (furosemide) dose based on volume status - reduce if patient becomes euvolemic or hypovolemic, as overdiuresis worsens hypotension and renal function 1
• Consider adding or adjusting Noractone (spironolactone/MRA) dose, as MRAs reduce mortality in HFrEF and do not significantly lower BP 1

Comprehensive GDMT Optimization

Quadruple Therapy for HFrEF

All four pillars of GDMT should be optimized: Entresto (ARNI), beta-blocker, MRA (Noractone), and SGLT2 inhibitor (Jardiance) 1, 2

• Jardiance (empagliflozin) should be continued - SGLT2 inhibitors reduce HF hospitalization and death, do not lower BP significantly, and are safe with eGFR as low as 20 mL/min/1.73m² 1
• Beta-blocker status unclear from medication list - if not on beta-blocker, consider starting low-dose selective β₁ blocker (bisoprolol, metoprolol succinate, or carvedilol) as tolerated, titrating slowly given low BP 1
• If beta-blocker not tolerated due to hypotension and patient in sinus rhythm with HR >70 bpm, consider ivabradine as alternative to facilitate rate control without BP lowering 1
• Noractone (MRA) should be continued unless hyperkalemia or severe renal dysfunction develops 1

Diabetes Management in HFrEF Context

Continue Jardiance (SGLT2 inhibitor) as first-line diabetes therapy in HFrEF - it provides dual benefit for both glycemic control and HF outcomes 1

• Metformin should be considered if eGFR >30 mL/min/1.73m² but is contraindicated if eGFR <30 1
• Continue Toujeo (insulin glargine) and Actrapid (regular insulin) for glycemic control - insulin is appropriate in advanced HFrEF when other agents insufficient 1
• Avoid thiazolidinediones (pioglitazone, rosiglitazone) completely - they are contraindicated in HF due to fluid retention and increased HF hospitalization risk 1
• Avoid saxagliptin (DPP-4 inhibitor) - associated with increased HF hospitalization 1
• Target HbA1c <7% but avoid hypoglycemia, as hypoglycemia can trigger arrhythmias in patients with ICDs 1

Addressing Recurrent Falls and Dizziness

Systematic Evaluation of Dizziness Etiology

Dizziness in this patient likely multifactorial: orthostatic hypotension from GDMT, volume depletion from overdiuresis, arrhythmias, or ICD shocks 1

• Check orthostatic vital signs - measure BP and HR supine and after 1-3 minutes standing 1
• Review ICD interrogation - assess for ventricular arrhythmias, inappropriate shocks, or pacing issues that could cause presyncope 1
• Assess for atrial fibrillation - AF is common in HF patients with diabetes and can cause hemodynamic instability 1
• Evaluate volume status carefully - overdiuresis is common cause of orthostatic hypotension in HF patients 1

Management Strategy for Hypotension-Related Dizziness

Patient education is first-line management for orthostatic symptoms - counsel on slow positional changes, adequate hydration, and compression stockings 1, 2

• Reduce diuretic dose if patient euvolemic or overdiuresed - this often resolves orthostatic symptoms without compromising HF therapy 1
• Do NOT reduce Entresto dose for asymptomatic or mildly symptomatic hypotension - benefits maintained regardless of baseline BP 1, 2
• If severe symptomatic hypotension persists, consider temporary Entresto dose reduction with plan to re-titrate - 40% of patients requiring temporary reduction can be restored to target doses 2
• Avoid alpha-blockers for BPH if possible - doxazosin, prazosin, terazosin cause orthostatic hypotension, especially in elderly 1

Anticoagulation and Arrhythmia Management

Atrial Fibrillation Screening and Anticoagulation

Screen for atrial fibrillation given age >65, diabetes, HF, and hypertension - AF increases stroke risk substantially 1

• If AF detected, anticoagulation is mandatory - use DOAC (apixaban, rivaroxaban, edoxaban, dabigatran) preferred over warfarin in diabetes 1
• Assess CHA₂DS₂-VASc score - this patient scores ≥4 (HF, hypertension, age 64, diabetes, vascular disease), indicating high stroke risk 1
• Continue aspirin and Plavix for PAD/CAD - but recognize increased bleeding risk with triple therapy (anticoagulation + DAPT) 1

ICD Management

Ensure ICD functioning appropriately - device therapy reduces sudden cardiac death in HFrEF with EF 25% 1

• Interrogate ICD for arrhythmias, shocks, or lead issues that could explain dizziness/falls 1
• Assess for CRT upgrade if QRS >130 ms and LBBB - cardiac resynchronization therapy improves outcomes in appropriate candidates 1

Hypertension Management in HFrEF Context

BP control is important but must be balanced against HF medication optimization 1

• Target BP <130/80 mmHg per ACC/AHA guidelines, but recognize that HFrEF patients often have lower BP on GDMT 1
• GDMT medications (Entresto, beta-blocker, MRA) provide BP control while treating HF - avoid adding non-GDMT antihypertensives if possible 1
• If additional BP lowering needed, consider amlodipine or other dihydropyridine CCB - these are safe in HFrEF unlike non-dihydropyridines 1

Renal Function and Electrolyte Monitoring

Close monitoring of renal function and potassium is essential with Entresto + MRA + diabetes 2, 3

• Monitor serum creatinine, eGFR, and potassium at baseline, 1-2 weeks after any dose change, and regularly thereafter 2, 3
• Mild creatinine elevation (<0.5 mg/dL increase) is acceptable and does not require dose adjustment 2
• Caution with potassium >5.0 mmol/L, especially with Entresto + Noractone (MRA) combination 2
• Adjust medications if eGFR declines significantly or hyperkalemia develops 1

Peripheral Arterial Disease Management

Aggressive risk factor modification and revascularization consideration are critical for limb salvage 1

• Continue aspirin 81-100 mg daily and Plavix 75 mg daily - dual antiplatelet therapy reduces cardiovascular events in symptomatic PAD 1
• Consider adding low-dose rivaroxaban 2.5 mg twice daily to aspirin (discontinue Plavix) - this combination reduces major adverse limb events in symptomatic PAD, though increases bleeding risk 1
• Optimize statin therapy with high-intensity statin (Crestor/rosuvastatin) - continue current regimen for atherosclerotic disease 1
• Urgent vascular surgery consultation for revascularization vs. amputation - near-total occlusion with gangrene requires intervention 1

Medication Reconciliation and Optimization

Current Medications to Continue

• Entresto (sacubitril/valsartan) - optimize to target dose 97/103 mg BID 1, 2, 3
• Jardiance (empagliflozin) - continue for HF and diabetes 1
• Noractone (spironolactone/MRA) - continue unless contraindicated 1
• Crestor (rosuvastatin) - continue high-intensity statin 1
• Aspirin and Plavix - continue for PAD/CAD 1
• Nexium (esomeprazole) - appropriate GI prophylaxis with DAPT 1
• Toujeo and Actrapid - continue insulin therapy 1
• Meropenem and linezolid - continue for infected gangrene 1

Medications Requiring Clarification

• Beta-blocker status unclear - should be on carvedilol, bisoprolol, or metoprolol succinate unless contraindicated 1
• Inhixa (enoxaparin) - assess indication; if for VTE prophylaxis, appropriate given immobility and HF 1
• Salurine (furosemide) - adjust dose based on volume status 1

Medications to Avoid

• Alpha-blockers for BPH - worsen orthostatic hypotension 1
• Thiazolidinediones - contraindicated in HF 1
• Saxagliptin - increases HF hospitalization risk 1

Common Pitfalls to Avoid

• Do not reduce or discontinue Entresto for asymptomatic or mildly symptomatic hypotension - this is the most common error and deprives patients of mortality benefit 1, 2
• Do not undertitrate GDMT medications - target doses provide maximum benefit 1, 2
• Do not delay vascular surgery consultation - limb-threatening ischemia requires urgent intervention 1
• Do not add non-GDMT antihypertensives before optimizing GDMT - GDMT medications provide BP control while treating HF 1
• Do not use thiazolidinediones or saxagliptin in HF patients - these worsen outcomes 1