How should I manage a 55-year-old man with type 2 diabetes (glycated hemoglobin 5.3%), hypertension controlled with losartan 60 mg daily and amlodipine 5 mg daily, on high‑intensity rosuvastatin (20 mg) with low LDL cholesterol (43 mg/dL), who presents with several days of intermittent chest tightness that improves after drinking Coca‑Cola, an ECG showing sinus rhythm with possible left‑ventricular hypertrophy, and a reduced left‑ventricular ejection fraction (~40%)?

Management of 55-Year-Old Man with Reduced LVEF, Suspected LVH, and Intermittent Chest Symptoms

Immediate Cardiac Workup Required

This patient requires urgent cardiology evaluation and comprehensive cardiac assessment before any medication adjustments, as he presents with new-onset heart failure with reduced ejection fraction (HFrEF) and concerning chest symptoms that may represent angina. 1

Critical Diagnostic Steps

• Obtain troponin levels immediately to rule out acute coronary syndrome, as chest symptoms relieved by Coca-Cola (likely caffeine effect or placebo) do not exclude ischemia 1
• Perform stress testing or coronary angiography to evaluate for left anterior descending (LAD) or multi-vessel coronary disease, particularly given the presence of LVH and reduced LVEF in a diabetic patient with multiple cardiovascular risk factors 1
• Repeat echocardiography to confirm LVEF 40%, assess wall motion abnormalities, quantify LVH severity, and evaluate diastolic function 2, 1
• Check BNP or NT-proBNP to confirm heart failure diagnosis and establish baseline for monitoring 2

Immediate Medical Therapy Optimization

Add Beta-Blocker Immediately

Initiate carvedilol 3.125 mg twice daily, metoprolol succinate 25 mg daily, or bisoprolol 1.25 mg daily and uptitrate to target doses over 8-12 weeks, as beta-blockers with proven mortality benefit are mandatory in HFrEF and should be continued indefinitely. 1 The American College of Cardiology specifically recommends only these three beta-blockers for patients with LVEF ≤40-50%. 1

Add SGLT2 Inhibitor for Dual Benefit

Add empagliflozin 10 mg daily, dapagliflozin 10 mg daily, or canagliflozin 100 mg daily immediately, as SGLT2 inhibitors with proven cardiovascular benefit are recommended for patients with type 2 diabetes and established heart failure with reduced ejection fraction to reduce risk of worsening heart failure and cardiovascular death. 2 These agents provide benefit independent of HbA1c level (his is already excellent at 5.3%) and should be added to his current regimen. 2, 3

• The cardiovascular benefits emerge within 3-6 months and are independent of glycemic control 3
• Expect an initial reversible eGFR decline of 3-5 mL/min/1.73 m², which is hemodynamic and should not prompt discontinuation 2, 3
• Discontinue SGLT2 inhibitor 3-4 days before any elective procedures to reduce diabetic ketoacidosis risk 2

Optimize Statin Therapy

Continue rosuvastatin 20 mg daily as this is appropriate high-intensity statin therapy. 2 His LDL of 43 mg/dL is well below the target of <70 mg/dL for patients with diabetes and cardiovascular disease. 2 No adjustment needed.

Continue Current Antihypertensive Regimen

Continue losartan 60 mg daily and amlodipine 5 mg daily as his blood pressure is well-controlled at 120/80 mmHg. 2 Losartan provides additional benefit for LVH regression in diabetic patients beyond blood pressure control. 4, 5 However, note that losartan provides greater LVH regression than amlodipine in diabetic patients with LVH (-19% vs -10% reduction in left ventricular mass index). 5

Consider Adding GLP-1 Receptor Agonist

Consider adding semaglutide 0.25 mg weekly, dulaglutide 0.75 mg weekly, or liraglutide 0.6 mg daily for additional cardiovascular benefit, as combined therapy with SGLT2 inhibitor and GLP-1 RA may provide additive reduction in cardiovascular and kidney events in patients with established cardiovascular disease or multiple risk factors. 2 This is particularly relevant given his HFrEF represents established cardiovascular disease.

Revascularization Assessment

Refer for coronary angiography to evaluate for significant LAD or multi-vessel disease, as CABG with LIMA to LAD is recommended for proximal LAD stenosis >70% with reduced LVEF, and provides superior long-term outcomes compared to medical therapy alone. 1 Calculate SYNTAX score if multi-vessel disease is found, with scores >22 favoring CABG over PCI. 1

Critical Monitoring Plan

• Reassess LVEF in 3-6 months after optimal medical therapy initiation to determine if improvement occurs 1
• Monitor for volume overload signs (peripheral edema, orthopnea, paroxysmal nocturnal dyspnea) and initiate loop diuretic if present 1
• Check baseline and follow-up eGFR, electrolytes, and urine albumin-to-creatinine ratio before and after starting SGLT2 inhibitor 2
• Obtain ECG to assess QRS duration; if QRS ≥120 msec with NYHA class II-IV symptoms despite optimal therapy, consider cardiac resynchronization therapy 1

Common Pitfalls to Avoid

• Do not delay beta-blocker initiation despite reduced LVEF; start low and titrate slowly, as these agents improve survival in HFrEF 1
• Do not discontinue SGLT2 inhibitor due to initial eGFR dip of 3-5 mL/min/1.73 m², as this is expected and reversible 2, 3
• Do not attribute chest symptoms to GERD or musculoskeletal causes without ruling out coronary disease in this high-risk patient 1
• Do not delay cardiology referral while optimizing medical therapy; both should occur simultaneously 1