Heart Failure Case Study

Let’s review the case of Mr. Doe, a 62-year-old Caucasian male who presents to the outpatient clinic after a recent hospitalization for ST elevation myocardial infarction. He has a past medical history of hypertension, dyslipidemia, and obesity. During the hospitalization, his cardiac catheterization revealed obstructive coronary artery disease, and the patient received a drug-eluting stent to the left anterior descending artery. His ejection fraction was noted to be 30-35% prior to discharge. He was started on aspirin, clopidogrel, atorvastatin, carvedilol, and lisinopril during his hospitalization and discharged with close outpatient cardiology clinic follow-up.

Mr. Doe presents to the outpatient cardiology clinic reporting mild shortness of breath with moderate exertional activities such as walking uphill or climbing one flight of stairs. He denies orthopnea, paroxysmal nocturnal dyspnea, or lower extremity edema. He denies chest pain, pressure, or tightness. He is eager to start exercising and is requesting exercise recommendations.

His blood pressure is 138/72, pulse 90, respiratory rate of 18 and an Sp02 of 98%. On physical exam, he is in no acute distress, speaking in full unlabored sentences. His jugular venous pressure is 8cm of H20, breath sounds are clear to auscultation, heart rhythm is regular, with S1 and S2 sounds, and no murmurs, gallops, or rubs are noted. His laboratory tests (basic metabolic panel, lipid panel, BNP, CBC, TSH, HIV) were unremarkable except for an abnormal BNP level of 450pg/mL.  

What therapies and treatment goals can be added to Mr. Doe’s care based on recent evidence and the importance of guideline-directed medical therapy to reduce morbidity, mortality and improve quality of life? 

Given Mr. Doe’s diagnosis of heart failure with reduced ejection fraction (HFrEF), he should be started on the four pillars of GDMT, including an angiotensin receptor-neprilysin inhibitor, mineralocorticoid receptor antagonist, one of the three approved beta-blockers for HFrEF, and an SGLT2 inhibitor. Because Mr. Doe is already on lisinopril, it will be stopped and transitioned to sacubitril/valsartan after a 36-hour washout period. He will continue his current dose of carvedilol 6.25mg BID. He will also be started on dapagliflozin 10mg and spironolactone 12.5mg daily. A basic metabolic panel and vital sign check will be obtained in one week to ensure that he is tolerating the new medications without renal impairment or alteration in his serum potassium levels. GDMT up-titration will occur every two weeks until the patient achieves maximally tolerated target doses. He will be referred to cardiac rehab to initiate an exercise program.  

After three months of maximally tolerated GDMT, an echocardiogram was repeated, revealing an improved ejection fraction of 60% He will continue all four pillars of GDMT and continue longitudinal follow-up in the outpatient cardiology clinic.  

Management of HFrEF requires timely initiation and up-titration of GDMT and is proven to reduce morbidity and mortality with benefits seen within the first 30 days of initiation. Therapeutic benefits are seen early after initiation of GDMT, so avoid therapeutic inertia in your clinical practice and start your patients with HFrEF on these life-saving medications early and up-titrate to doses where the most benefit was found in clinical trials.  

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References: 

1. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association 
2. Yancy CW, Jessup M, Bozkurt B, et al. 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. J Am Coll Cardiol. 2017;70(6):776-803. doi:10.1016/j.jacc.2017.04.025 Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;62(16):e147-e239. doi:10.1016/j.jacc.2013.05.019 
3. Writing Committee, Maddox TM, Januzzi JL Jr, et al. 2021 Update to the 2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment: Answers to 10 Pivotal Issues About Heart Failure With Reduced Ejection Fraction: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. 2021;77(6):772-810. doi:10.1016/j.jacc.2020.11.022