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), DM2 (type 2 diabetes mellitus), and a current smoker, presenting with bradycardia, hypertension, and pitting edema, with a reduced LVEF (left ventricular ejection fraction) of 45-50% and hyperkalemia?

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

The provider should immediately restart a beta-blocker (bisoprolol, carvedilol, or metoprolol succinate) despite bradycardia since the patient is asymptomatic, continue dapagliflozin as it provides mortality benefit in HFmrEF with diabetes, optimize blood pressure control with increased hydrochlorothiazide, and address smoking cessation aggressively as the single most modifiable risk factor. 1

Critical Medication Priorities for HFmrEF

Beta-Blocker Therapy is Essential

• Beta-blockers must be initiated in all patients with reduced or mid-range LVEF (45-50%), even when asymptomatic and bradycardic, as they reduce mortality and prevent disease progression. 2, 1
• The three proven beta-blockers (bisoprolol, carvedilol, or sustained-release metoprolol succinate) should be started at low doses and titrated to target doses as tolerated, regardless of baseline heart rate when the patient has no symptoms from bradycardia. 2, 1
• Asymptomatic bradycardia at 45 bpm is NOT a contraindication to beta-blocker therapy in heart failure—symptomatic bradycardia with lightheadedness or dizziness would be the concern, which this patient explicitly denies. 1
• The provider's decision to discontinue atenolol was appropriate initially, but restarting a guideline-directed beta-blocker is now mandatory given the confirmed HFmrEF diagnosis. 1, 2

SGLT2 Inhibitor Continuation

• Dapagliflozin 10 mg daily should be continued as it reduces cardiovascular death and heart failure hospitalizations in patients with HFmrEF and diabetes, irrespective of ejection fraction. 1, 3
• SGLT2 inhibitors have proven efficacy in reducing hard outcomes (CV death, HF hospitalizations) in elderly HFmrEF patients with diabetes mellitus. 1, 3

ACE Inhibitor Optimization

• Lisinopril 40 mg daily is appropriate and should be continued as ACE inhibitors are Class I recommendations for all patients with current or prior heart failure symptoms to improve survival. 2, 1
• ACE inhibitors should be maintained even with mildly elevated potassium (5.4 mEq/L) unless potassium exceeds 5.5-6.0 mEq/L, as the mortality benefit outweighs the risk. 1

Blood Pressure Management Strategy

Current Approach is Correct

• Discontinuing spironolactone due to hyperkalemia (5.4 mEq/L) was appropriate, as mineralocorticoid receptor antagonists commonly cause hyperkalemia in elderly patients with renal dysfunction. 1
• Increasing hydrochlorothiazide to 50 mg daily for blood pressure control is reasonable, though close monitoring of renal function and electrolytes is essential. 4, 1
• Target blood pressure should be <130/80 mmHg in patients with heart failure and diabetes. 2, 3

Monitoring Considerations

• Check BMP in 2-4 weeks (not 1 month) after medication changes to ensure potassium normalizes and renal function remains stable. 4
• Diuretics combined with ACE inhibitors and SGLT2 inhibitors require careful monitoring for volume depletion and renal hypoperfusion. 4, 3

Bradycardia Management

Asymptomatic Bradycardia Does Not Require Intervention

• The patient's bradycardia at 45 bpm with RBBB is asymptomatic (no lightheadedness, dizziness, or syncope), therefore pacemaker placement is not indicated. 1
• Beta-blocker therapy should still be initiated despite baseline bradycardia of 45 bpm, starting at the lowest dose and monitoring heart rate. 1, 2
• If heart rate drops below 40 bpm or symptoms develop after beta-blocker initiation, consider ivabradine as an alternative, though it is typically reserved for heart rates >70 bpm in symptomatic patients. 1

Smoking Cessation is Critical

Highest Priority Modifiable Risk Factor

• Smoking cessation must be addressed aggressively at every visit as it is the single most important modifiable risk factor in this patient with PVD, CAD risk, and heart failure. 1
• Refer to smoking cessation programs, consider pharmacotherapy (varenicline or bupropion), and provide nicotine replacement therapy. 1
• Continued smoking accelerates heart failure progression, increases cardiovascular events, and worsens peripheral vascular disease. 1

Diabetes Management Considerations

Current Therapy is Optimal

• SGLT2 inhibitors (dapagliflozin) are the preferred diabetes medication in patients with heart failure, providing both glycemic control and cardiovascular benefit. 1
• Avoid thiazolidinediones (pioglitazone, rosiglitazone) as they increase heart failure risk and hospitalizations. 1
• Avoid saxagliptin (DPP-4 inhibitor) as it increases heart failure hospitalization risk. 1
• GLP-1 receptor agonists (liraglutide, semaglutide) have neutral effects on heart failure hospitalization and may be considered if additional glycemic control is needed. 1

Atrial Fibrillation Screening and Anticoagulation

Screen for Atrial Fibrillation

• This elderly patient with heart failure, hypertension, diabetes, and PVD should be screened for atrial fibrillation by pulse palpation or wearable devices at every visit. 1
• If atrial fibrillation is detected, anticoagulation with a DOAC (apixaban, rivaroxaban, edoxaban, or dabigatran) is mandatory given his CHA₂DS₂-VASc score of at least 4 (heart failure, hypertension, diabetes, age ≥65, vascular disease). 1, 5
• DOACs are preferred over warfarin due to lower intracranial hemorrhage risk and similar efficacy. 1

Follow-Up Echocardiogram Interpretation

HFmrEF Classification and Implications

• The patient's LVEF of 45-50% classifies him as HFmrEF, which represents an intermediate phenotype that responds to HFrEF therapies. 1, 6, 7
• HFmrEF patients have similar mortality rates to HFrEF and HFpEF patients (approximately 40% at 2-3 years), emphasizing the need for aggressive guideline-directed medical therapy. 6, 8
• HFmrEF patients often have coronary artery disease as the underlying etiology and benefit from NT-proBNP-guided therapy similar to HFrEF patients. 6

Common Pitfalls to Avoid

Do Not Delay Beta-Blocker Therapy

• The most critical error would be continuing to withhold beta-blocker therapy due to asymptomatic bradycardia—this patient requires beta-blockade for mortality benefit. 1, 2
• Start with the lowest dose (e.g., carvedilol 3.125 mg twice daily or metoprolol succinate 12.5-25 mg daily) and titrate slowly while monitoring heart rate and symptoms. 1

Do Not Overtitrate Diuretics

• Elderly patients with HFmrEF are particularly sensitive to volume depletion, which can cause renal dysfunction and hypotension. 3
• The patient is currently euvolemic—do not increase diuretics further unless edema recurs. 3

Do Not Ignore Renal Function

• Combination of ACE inhibitor, diuretic, and SGLT2 inhibitor requires close monitoring of creatinine and electrolytes every 2-4 weeks initially. 4
• Renal hypoperfusion can occur through decreased cardiac output and neurohumoral activation in heart failure. 4

Do Not Restart Spironolactone Without Addressing Hyperkalemia

• Spironolactone should only be reconsidered if potassium normalizes (<5.0 mEq/L) and remains stable, as it provides mortality benefit in HFrEF/HFmrEF but carries significant hyperkalemia risk in elderly patients. 1

Six-Month Follow-Up Plan

Repeat Echocardiogram Assessment

• Assess for LVEF recovery or decline—if LVEF decreases to ≤35% despite optimal medical therapy, consider ICD placement for primary prevention of sudden cardiac death. 2, 1
• Evaluate for new valvular abnormalities, particularly secondary mitral regurgitation which can worsen with ventricular remodeling. 1

Medication Titration Goals

• Target beta-blocker doses: carvedilol 25 mg twice daily, metoprolol succinate 200 mg daily, or bisoprolol 10 mg daily. 1
• Ensure ACE inhibitor is at target dose (lisinopril 40 mg daily is appropriate). 1
• Continue dapagliflozin 10 mg daily indefinitely. 1

Blood Pressure and Heart Rate Targets

• Blood pressure goal: <130/80 mmHg. 2
• Heart rate goal: 50-70 bpm on beta-blocker therapy (lenient control acceptable if asymptomatic). 1