What is the best management approach for an elderly male patient with HFmrEF (Heart Failure with mid-range ejection fraction), HTN (Hypertension), PVD (Peripheral Vascular Disease), HLD (Hyperlipidemia), and DM2 (Diabetes Mellitus type 2), who is a current smoker, presenting with bradycardia, hypertension, and hyperkalemia, and currently on spironolactone, lisinopril, hydrochlorothiazide, atorvastatin, clopidogrel, aspirin, and metformin?

Management of Elderly Male with HFmrEF, Hypertension, Bradycardia, and Hyperkalemia

Immediate Priority: Address Hyperkalemia and Discontinue Spironolactone

The spironolactone must be discontinued immediately given the potassium of 5.4 mEq/L in a patient on triple RAAS blockade (lisinopril, spironolactone, and hydrochlorothiazide). 1, 2 The combination of an ACE inhibitor with a mineralocorticoid receptor antagonist (MRA) significantly increases hyperkalemia risk, particularly in patients with any degree of renal impairment. 1, 2

Why Spironolactone Must Be Stopped Now

• Spironolactone carries FDA warnings about hyperkalemia risk that is "increased by impaired renal function or concomitant potassium supplementation...or drugs that increase potassium, such as angiotensin converting enzyme inhibitors." 2
• The patient is on lisinopril 40 mg daily plus spironolactone 25 mg daily—this dual RAAS blockade creates compounding hyperkalemia risk. 1, 2
• Even though 5.4 mEq/L is not immediately life-threatening, continuation of spironolactone will likely worsen hyperkalemia and force discontinuation of the more beneficial lisinopril. 1

Recheck Potassium Within One Week

• Monitor serum potassium within 1 week after discontinuing spironolactone, as recommended by FDA labeling. 2
• If potassium normalizes (<5.0 mEq/L), the patient can proceed with optimized HFmrEF therapy without spironolactone. 1

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Blood Pressure Management: Add SGLT2 Inhibitor Before Restarting Spironolactone

Instead of restarting or increasing spironolactone, add an SGLT2 inhibitor (empagliflozin or dapagliflozin) as the next step for both blood pressure control and HFmrEF management. 1

Why SGLT2 Inhibitors Are the Optimal Choice

• SGLT2 inhibitors reduce serious hyperkalemia risk (hazard ratio 0.84; 95% CI 0.76–0.93) in patients on RAAS inhibitors and MRAs. 1 This creates an opportunity to maintain lisinopril at full dose while improving cardiovascular outcomes.
• SGLT2 inhibitors are recommended for all patients with symptomatic HFmrEF to improve outcomes, with modest blood pressure-lowering properties (typically 3-5 mmHg systolic reduction). 1
• They require no dose adjustment, do not affect heart rate (critical in this bradycardic patient), and work effectively even with moderate kidney dysfunction (eGFR ≥30 mL/min/1.73 m² for empagliflozin; ≥20 mL/min/1.73 m² for dapagliflozin). 1
• Treatment benefits occur within weeks and are independent of background medical therapy optimization. 1

Specific SGLT2 Inhibitor Dosing

• Start empagliflozin 10 mg daily or dapagliflozin 10 mg daily. 1
• These agents are particularly beneficial in patients with diabetes (which this patient has), providing dual cardiovascular and glycemic benefits. 1

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Blood Pressure Target and Additional Antihypertensive Strategy

Target systolic blood pressure to 130-139 mmHg in this elderly patient with diabetes and CKD. 1

If Blood Pressure Remains Elevated After SGLT2 Inhibitor Addition

• Increase hydrochlorothiazide from 25 mg to 50 mg daily as the next step, since thiazide-like diuretics remain effective even with moderate renal impairment and provide additional blood pressure reduction. 1, 3
• The 2024 ESC guidelines recommend reinforcement of lifestyle measures, especially sodium restriction, as foundational therapy for resistant hypertension. 1
• If blood pressure remains uncontrolled after maximizing hydrochlorothiazide, consider adding a dihydropyridine calcium channel blocker (amlodipine 5-10 mg daily) rather than restarting spironolactone. 1

Critical Caveat About Spironolactone Reintroduction

• Spironolactone can be reconsidered only if: (1) potassium normalizes and remains <4.5 mEq/L, (2) renal function is stable, (3) blood pressure remains uncontrolled despite SGLT2 inhibitor + maximized thiazide + calcium channel blocker, and (4) potassium is monitored weekly for the first month. 1, 3, 2
• The 2024 ESC guidelines recommend spironolactone as first-line add-on therapy for resistant hypertension, but this patient's hyperkalemia makes it inappropriate at this time. 1, 3

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Heart Failure Management: Initiate Beta-Blocker Despite Bradycardia

Start a low-dose evidence-based beta-blocker (carvedilol 3.125 mg twice daily, bisoprolol 1.25 mg daily, or metoprolol succinate 12.5-25 mg daily) despite the baseline heart rate of 45 bpm, as the patient is asymptomatic. 1

Rationale for Beta-Blocker Initiation

• Beta-blockers are Class I recommendations for all patients with current or prior symptoms of HFmrEF/HFrEF (LVEF 45-50% qualifies), unless contraindicated, to reduce morbidity and mortality. 1
• Asymptomatic bradycardia is not an absolute contraindication—beta-blockers "may be considered in patients with...asymptomatic bradycardia but should be used cautiously." 1
• The patient's bradycardia improved after discontinuing atenolol, suggesting the baseline rate may be higher than 45 bpm without beta-blockade. 1

Beta-Blocker Titration Strategy

• Initiate at very low doses and uptitrate gradually every 2-4 weeks as tolerated, monitoring heart rate and blood pressure closely. 1
• Target heart rate should be 50-60 bpm at rest; if heart rate drops below 50 bpm or symptoms develop (lightheadedness, dizziness, syncope), hold uptitration or reduce dose. 1
• Approximately 85% of patients in clinical trials tolerated beta-blockers and achieved target doses using this cautious approach. 1

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Guideline-Directed Medical Therapy (GDMT) Optimization for HFmrEF

The patient requires comprehensive GDMT including ACE inhibitor (or ARNI), beta-blocker, and SGLT2 inhibitor as core therapies. 1

Current Medication Assessment

• Lisinopril 40 mg daily: Appropriate dose; continue. 1
• Hydrochlorothiazide 25 mg daily: Appropriate for volume management and blood pressure; may increase to 50 mg if needed. 1
• Spironolactone 25 mg daily: Discontinue due to hyperkalemia. 1, 2
• Beta-blocker: Not currently prescribed; must initiate. 1
• SGLT2 inhibitor: Not currently prescribed; must add. 1

Consider ARNI (Sacubitril/Valsartan) as Future Step

• If the patient remains symptomatic despite ACE inhibitor, beta-blocker, and SGLT2 inhibitor, consider switching from lisinopril to sacubitril/valsartan (Entresto). 1
• Sacubitril/valsartan is indicated to reduce HF hospitalization and death in patients with HFmrEF/HFrEF who remain symptomatic despite optimal medical therapy. 1
• Requires 36-hour washout period after stopping ACE inhibitor to avoid angioedema risk. 1

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Smoking Cessation: Mandatory Intervention

Initiate pharmacological smoking cessation therapy immediately, as continued smoking significantly worsens cardiovascular outcomes in patients with HFmrEF, diabetes, and peripheral vascular disease. 4, 5, 6

Evidence-Based Smoking Cessation Strategies

• Offer nicotine replacement therapy (NRT), varenicline, or bupropion—all are effective and safe even in patients with chronic cardiovascular disease. 4
• Varenicline and combination NRT (patch + gum/lozenge) have the highest quit rates. 4
• Older smokers (≥50 years) derive significant health benefits from quitting and respond well to physician-delivered brief counseling combined with pharmacotherapy. 5, 6

Practical Implementation

• Use a four-step approach: Ask about smoking, Advise to quit, Assist in developing a quit plan, and Arrange follow-up. 5
• Tailor interventions to older smokers by addressing barriers such as nicotine withdrawal, doubted self-efficacy, and misperceptions of little gain from quitting. 7, 5
• Self-reported quit rates at 6 months are approximately 15% with physician-delivered brief counseling versus 8% with usual care. 6

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Monitoring Plan

Immediate (Within 1 Week)

• Recheck basic metabolic panel (BMP) to assess potassium, sodium, and creatinine after discontinuing spironolactone. 1, 2
• Assess blood pressure response and volume status. 1

Short-Term (2-4 Weeks)

• Recheck BMP after initiating SGLT2 inhibitor to monitor for transient eGFR decline (expected and not harmful). 1
• Assess heart rate and blood pressure after initiating beta-blocker. 1
• Evaluate smoking cessation progress and adjust pharmacotherapy as needed. 4, 5

Long-Term (Every 3 Months)

• Monitor potassium, creatinine, and eGFR regularly, especially if considering reintroduction of spironolactone. 1, 2
• Assess HF symptoms, functional status, and blood pressure control. 1
• Continue smoking cessation support with follow-up counseling. 5, 6

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Critical Pitfalls to Avoid

• Never continue spironolactone in the setting of hyperkalemia (K ≥5.0 mEq/L) on dual RAAS blockade—this will worsen hyperkalemia and potentially force discontinuation of the more beneficial ACE inhibitor. 1, 2
• Do not attribute bradycardia as an absolute contraindication to beta-blockers in asymptomatic patients with HFmrEF—cautious initiation at low doses is appropriate and potentially life-saving. 1
• Avoid adding additional RAAS blockers (ARBs, direct renin inhibitors) to ACE inhibitor therapy—dual RAAS blockade increases risks of hypotension, worsening renal function, hyperkalemia, and stroke without additional benefit. 1, 8
• Do not restart spironolactone without first optimizing SGLT2 inhibitor and thiazide diuretic therapy—SGLT2 inhibitors reduce hyperkalemia risk and provide superior cardiovascular and renal protection. 1
• Never overlook smoking cessation counseling in elderly patients—older smokers derive substantial health benefits from quitting and respond well to physician-delivered interventions. 4, 7, 5, 6