What is the best management plan for a 57-year-old female with a past medical history of Heart Failure with preserved Ejection Fraction (HFpEF), paroxysmal Atrial Fibrillation (A-fib) on warfarin (Coumadin), poorly controlled Type 2 Diabetes Mellitus (DM 2), Hypertension (HTN), Hyperlipidemia (HLD), and Chronic Obstructive Pulmonary Disease (COPD), presenting with increased edema, weight gain, and shortness of breath?

Management of HFpEF with Acute Decompensation and Multiple Comorbidities

Continue Bumex 1 mg twice daily for persistent volume overload, initiate Repatha for statin-intolerant dyslipidemia, continue Ozempic (GLP-1 agonist) for diabetes/HF benefit, maintain warfarin for paroxysmal atrial fibrillation with moderate mitral stenosis, and ensure Farxiga (SGLT2 inhibitor) is optimized as foundational HFpEF therapy. 1, 2

Immediate Diuretic Management for Volume Overload

• Loop diuretics remain the cornerstone for symptom management in volume-overloaded HFpEF patients, and your patient's 8-pound weight gain over 10 days with increased edema and dyspnea clearly indicates inadequate diuresis 1, 2
• Continue Bumex 1 mg twice daily as the patient demonstrated improvement with this dose previously, though close monitoring is essential given her BNP of 150 and persistent symptoms 1
• Daily weights should continue with instructions to call if weight increases >2-3 pounds in 1 day or >5 pounds in 1 week 2
• Reassess volume status at the 1-month follow-up with physical exam focusing on jugular venous pressure, peripheral edema, pulmonary rales, and repeat BNP 2

Foundational HFpEF Pharmacotherapy

• SGLT2 inhibitors (Farxiga/dapagliflozin) are first-line therapy for HFpEF with Class 2a recommendation for symptomatic HF with LVEF ≥50%, reducing HF hospitalization or cardiovascular death by approximately 20% 1, 2
• Ensure Farxiga is continued at 10 mg daily and monitor for euglycemic ketoacidosis, though this is rare 1
• GLP-1 agonists (Ozempic/semaglutide) provide additional benefit in patients with diabetes, obesity, and HFpEF through weight loss, improved glycemic control, and potential cardiovascular benefits 2, 3
• The combination of SGLT2 inhibitor plus GLP-1 agonist is particularly appropriate given her poorly controlled diabetes, obesity (implied by weight gain pattern), and HFpEF 3

Anticoagulation Strategy for Paroxysmal Atrial Fibrillation

• Warfarin is the correct anticoagulant choice in this patient due to moderate mitral stenosis, as DOACs are contraindicated in moderate-to-severe mitral stenosis 4, 5
• Target INR should be 2.0-3.0 with time in therapeutic range (TTR) >70% to ensure safety and effectiveness 4
• Her CHA₂DS₂-VASc score is at least 5 (HF=1, HTN=1, Age 65-74=1, DM=1, Vascular disease likely=1), making anticoagulation absolutely essential 4
• Monitor INR closely, especially with initiation of new medications that may interact with warfarin metabolism 4

Lipid Management in Statin-Intolerant Patient

• Repatha (evolocumab, a PCSK9 inhibitor) is an appropriate choice for statin-intolerant patients with elevated LDL and cardiovascular disease, particularly given her likely coronary disease (elevated troponin during hospitalization) 5
• Repatha 140 mg subcutaneously every 2 weeks or 420 mg monthly can reduce LDL by 50-60% 5
• The elevated triglycerides noted should also be addressed; ensure GLP-1 agonist therapy is optimized as it can improve triglyceride levels 3
• Lifestyle modifications including heart-healthy diet and alcohol moderation are essential, as alcohol excess can worsen both atrial fibrillation and heart failure 4, 5

Critical Medication Considerations and Pitfalls

• Avoid nondihydropyridine calcium channel blockers (diltiazem, verapamil) entirely as they may worsen heart failure and are contraindicated in decompensated HF 4, 6, 1
• Avoid thiazolidinediones (pioglitazone, rosiglitazone) for diabetes management as they cause fluid retention and increase HF hospitalization risk 3
• Avoid saxagliptin and alogliptin (DPP-4 inhibitors) as they are associated with increased HF risk 3
• Beta-blockers may be used cautiously for rate control if atrial fibrillation recurs, but are not Class I indicated for HFpEF in sinus rhythm 1, 7
• Monitor potassium and renal function closely given SGLT2 inhibitor use and potential future consideration of mineralocorticoid receptor antagonist (spironolactone) if symptoms persist despite current therapy 1

Monitoring the Moderate Mitral Stenosis

• The planned repeat echocardiogram in 4 months is appropriate to assess progression of mitral stenosis 4
• If mitral stenosis progresses to severe (valve area <1.5 cm²) with symptoms, percutaneous balloon valvuloplasty or surgical intervention may be needed 4
• Maintain strict rate control if atrial fibrillation recurs, as rapid ventricular response is particularly poorly tolerated in mitral stenosis 4, 6

Addressing Hyperkalemia Risk

• The peaked T waves on prior EKG warrant immediate CMP at the next visit to assess potassium level 1
• If hyperkalemia is confirmed, evaluate for causes including SGLT2 inhibitor effect, renal dysfunction, or dietary potassium excess 1
• This finding may preclude addition of mineralocorticoid receptor antagonist (spironolactone) unless potassium normalizes and eGFR >30 mL/min/1.73m² 1

Exercise and Lifestyle Modifications

• Exercise training produces clinically meaningful increases in functional capacity and quality of life in HFpEF patients and should be strongly encouraged 2
• Cardiac rehabilitation enrollment is recommended if available, with target of 150-300 minutes per week of moderate intensity aerobic activity 4, 2
• Weight loss through diet is essential given the association between obesity and HFpEF progression 4, 2
• Sodium restriction to <2-3 grams daily helps minimize fluid retention 4, 2
• Alcohol cessation or significant reduction is strongly recommended as alcohol excess is a modifiable risk factor for AF recurrence and HF progression 4, 5

Follow-Up Protocol at 1 Month

• Assess volume status with physical exam, daily weight log review, and repeat BNP 2
• Check CMP for potassium, renal function (eGFR), and glucose control 1
• Verify fasting lipid panel to assess Repatha efficacy 5
• Review INR and warfarin dosing to ensure therapeutic anticoagulation 4
• Assess functional capacity with 6-minute walk test or symptom assessment using modified EHRA scale 1, 2
• Evaluate for adverse effects of new medications (Repatha, Ozempic) 5, 3