From the Guidelines
The patient should be started on levothyroxine therapy, iron supplementation, and continue diuresis with IV furosemide, while maintaining therapeutic anticoagulation with warfarin and monitoring digoxin levels. The patient is a 58-year-old female with multiple cardiac issues including rheumatic heart disease, mechanical mitral valve replacement, heart failure with reduced ejection fraction, atrial fibrillation, and other comorbidities who is currently admitted for acute decompensated heart failure. Lab results show mild anemia (Hb 9.9), therapeutic anticoagulation (INR 3.3), iron deficiency (low transferrin saturation 8%, low serum iron 25), and significantly elevated hypothyroidism (TSH 8.729) with markedly elevated pro-BNP (9,349) indicating heart failure.
The next steps should include:
- Starting levothyroxine therapy (typically 50-75 mcg daily) for hypothyroidism, which is likely contributing to heart failure symptoms 1
- Initiating iron supplementation (ferrous sulfate 325 mg daily or every other day) to address iron deficiency
- Continuing diuresis with IV furosemide while monitoring electrolytes and renal function daily
- Considering adding spironolactone 25 mg daily and/or an ACE inhibitor/ARB if blood pressure allows for guideline-directed heart failure therapy
- Maintaining therapeutic anticoagulation with current warfarin dosing, as recommended for patients with mechanical heart valves 1
- Monitoring digoxin levels given renal function and potential drug interactions
Treating the hypothyroidism is particularly important as it can worsen heart failure and contribute to symptoms. The iron deficiency should be addressed as it can exacerbate heart failure symptoms even without severe anemia. Optimizing guideline-directed medical therapy for heart failure will improve outcomes once the patient is euvolemic. Daily weights, strict fluid restriction (1.5-2L/day), and low sodium diet should also be implemented during hospitalization.
Key considerations for anticoagulation therapy in this patient include the presence of a mechanical mitral valve and atrial fibrillation, which increase the risk of thromboembolic events. The current warfarin dosing should be maintained to achieve a therapeutic INR, as recommended by guidelines 1.
Overall, a comprehensive approach to managing this patient's heart failure, hypothyroidism, iron deficiency, and anticoagulation therapy is necessary to improve outcomes and reduce morbidity and mortality.
From the FDA Drug Label
For all patients with mechanical prosthetic heart valves, warfarin is recommended. For patients with a St. Jude Medical (St. Paul, MN) bileaflet valve in the aortic position, a target INR of 2.5 (range, 2.0 to 3. 0) is recommended.
The patient has a mechanical MVR and is on warfarin with an INR of 3.3, which is within the recommended range of 2.0 to 3.0 for patients with mechanical prosthetic heart valves. Key points:
- The patient's current INR is 3.3, which is within the therapeutic range.
- The patient's warfarin dose is 6 mg/d, and no adjustment is needed at this time.
- Next steps:
- Continue to monitor the patient's INR levels regularly to ensure they remain within the therapeutic range.
- Adjust the warfarin dose as needed to maintain an INR between 2.0 and 3.0 2.
From the Research
Patient Profile
- 58-year-old female with a past medical history (PMHx) of rheumatic heart disease (RHD), status post mechanical mitral valve replacement (MVR) in 2008 on coumadin, MVR in 1993, heart failure with reduced ejection fraction (HFrEF) with an ejection fraction (EF) of 25%, atrial fibrillation (A-fib), asthma, diabetes mellitus (DM), anemia, varicose veins, admitted with acute decompensated heart failure (ADHF)
Laboratory Results
- WBC: 5.3
- Hb: 9.9
- HCT: 33.2
- PLT: 350
- MCV: 98.2
- PTT: 56.1
- INR: 3.3
- PT: 34.9
- Cr: 0.7
- K: 4.4
- Na: 140
- Mg: 2.0
- Ca: 8.8
- Chloride: 98
- Glucose: 104
- CO2 total: 32.2
- eGFR: 87
- ProBNP: 9,349
- TSH: 8.729
- A1C: 6.0%
- Transferrin serum: 315
- Transferrin sat: 8
- TIBC: 329
- Iron serum: 25
- B12: 540
- T4 free: 1.0
- Ted disturb width: 11.7
- Mean corp hgb: 29.3
- Mean corp hgb conc: 29.8
Medications
- Digoxin 0.125 mg
- Furosemide 80 mg/tid IV
- Metformin 500 mg/bid
- Montelukast 10 mg/d
- Pulmicort 0.5 mg/bid
- Perforomist 20 mcg/bid
- Rosuvastatin 20 mg/d
- Sitagliptin 25 mg/d
- Warfarin 6 mg/d
Next Steps
- Based on the patient's laboratory results, she has anemia (Hb: 9.9) and iron deficiency (Transferrin sat: 8, Iron serum: 25) 3
- The patient's heart failure with reduced ejection fraction (HFrEF) and anemia may benefit from optimization of medical therapy, including the use of intravenous iron supplementation 4, 3
- The patient's diabetes mellitus (DM) is well-controlled (A1C: 6.0%), but her atrial fibrillation (A-fib) may require further management 5
- The patient's current medications, including digoxin, furosemide, metformin, and warfarin, should be optimized and monitored closely 6
- Further evaluation of the patient's iron deficiency and anemia may be necessary, including assessment of underlying causes and consideration of erythropoiesis-stimulating agents (ESAs) or intravenous iron therapy 7, 4