Pharmacotherapy Case Study 5: Heart Failure with Reduced Ejection Fraction By Dr. Nehad Ahmed

 

Chief Complaint:

The patient presents with complaints of increasing shortness of breath, fatigue, and swelling in the legs over the past two weeks. The patient notes that the symptoms have worsened with physical exertion and have been interfering with daily activities.

Subjective Data:

History of Present Illness (HPI):
The patient reports increasing shortness of breath over the last two weeks, especially during exertion and when lying flat at night. The patient has also noticed bilateral swelling in the ankles and legs, which worsens as the day progresses. The shortness of breath is worse when walking up stairs or walking longer distances. The patient also experiences nocturnal cough, particularly at night, which has disrupted sleep. The patient denies any chest pain but reports feeling unusually fatigued and has difficulty completing daily tasks.

Past Medical History (PMH):

Heart Failure with Reduced Ejection Fraction (HFrEF) diagnosed 3 years ago

Hypertension (diagnosed 10 years ago)

Type 2 diabetes mellitus

Hyperlipidemia

Previous myocardial infarction (MI) 5 years ago

Chronic kidney disease (stage 2, stable)

Medications:

Lisinopril 20 mg daily

Carvedilol 25 mg twice daily

Furosemide 40 mg daily

Aspirin 81 mg daily

Atorvastatin 40 mg nightly

Metformin 500 mg twice daily

Spironolactone 25 mg daily

Allergies:

No known drug allergies.

Family History:

Father with heart disease and hypertension

Mother with a history of stroke at age 60

No significant family history of heart failure or arrhythmias.

Social History:

Non-smoker

Occasional alcohol use (1-2 drinks per week)

Sedentary lifestyle with little to no regular physical activity

Diet is high in processed foods, low in fruits and vegetables

Stress related to work and family life

 

Review of Systems:

Cardiovascular: Increasing shortness of breath, bilateral lower extremity edema, nocturnal cough, fatigue.

Neurological: No dizziness, syncope, or recent changes in memory.

Respiratory: Shortness of breath with exertion and at night, no wheezing or hemoptysis.

Gastrointestinal: No nausea, vomiting, or abdominal pain.

Endocrine: No significant changes in appetite or thirst, stable blood glucose levels.

Objective Data:

Vital Signs upon Arrival:

Blood Pressure: 130/85 mmHg

Heart Rate: 92 bpm

Respiratory Rate: 22 breaths/min

Temperature: 36.8°C

Oxygen Saturation: 95% on room air

Weight: 95 kg (BMI 32 kg/m²)

Height: 170 cm

Physical Exam:

General: Alert, mildly distressed due to shortness of breath, no acute distress.

 

Cardiovascular:

Regular rhythm, no murmurs or gallops noted.

Bilateral pitting edema in the lower extremities, more prominent on the left.

Jugular venous distention (JVD) noted at 45-degree angle.

Respiratory:

Mild crackles at the bases of the lungs, no wheezing.

No use of accessory muscles for breathing.

Abdomen: Soft, non-tender, no hepatomegaly or ascites.

Extremities:

Bilateral lower extremity edema, pitting grade 2+.

No cyanosis or clubbing.

Skin: Warm and dry, no rashes or lesions.

Laboratory Results:

Electrolytes: Sodium 140 mEq/L, Potassium 4.0 mEq/L

Creatinine: 1.1 mg/dL (stable from baseline)

Blood Glucose: 108 mg/dL (fasting)

B-type Natriuretic Peptide (BNP): 850 pg/mL (elevated)

Hemoglobin A1c: 7.2%

Lipid Profile:

Total Cholesterol: 220 mg/dL

LDL: 145 mg/dL

HDL: 42 mg/dL

Triglycerides: 160 mg/dL

Electrocardiogram (ECG):

Sinus rhythm with occasional premature ventricular contractions (PVCs), no signs of acute ischemia.

Heart rate of 92 bpm with normal axis and intervals.

Echocardiogram:

Left Ventricular Ejection Fraction (LVEF): 35% (reduced, confirming HFrEF)

Mild mitral regurgitation, no significant valvular disease.

Mild left ventricular hypertrophy.

Chest X-ray:

Mild bilateral pleural effusions, mild cardiomegaly.

No acute consolidation or pneumothorax.

Assessment:

The patient has Heart Failure with Reduced Ejection Fraction (HFrEF), likely secondary to a previous myocardial infarction (MI) and long-standing hypertension. The current presentation of increasing shortness of breath, bilateral lower extremity edema, nocturnal cough, and elevated BNP levels are consistent with worsening heart failure. The reduced ejection fraction (35%) on echocardiogram confirms the diagnosis of HFrEF.

Key issues:

Volume overload (evidenced by bilateral lower extremity edema, elevated BNP, and crackles on lung examination) is likely due to inadequate cardiac output.

Symptom progression over the past two weeks, suggesting a decompensation of heart failure.

Renal function is stable, but monitoring is necessary, especially with the use of diuretics and other heart failure medications.

Type 2 diabetes is stable but requires ongoing management to reduce cardiovascular risk.

Hypertension remains a concern as it may contribute to further cardiac remodeling and worsening of heart failure.

Plan:

Immediate Management:

Optimize heart failure therapy:

Increase furosemide dose to 80 mg daily, with adjustments based on response, to manage fluid overload.

Add hydralazine and isosorbide dinitrate (if not already on these medications) to reduce afterload and improve symptoms. Start hydralazine 25 mg three times daily and isosorbide dinitrate 20 mg three times daily.

Monitor renal function and electrolytes closely, especially potassium and creatinine, with diuretic dose adjustments.

Reassess the need for aldosterone antagonists (spironolactone 25 mg daily), ensuring potassium levels remain within range.

 

Pharmacotherapy Adjustments:

ACE Inhibitor (Lisinopril 20 mg daily) is appropriate; continue at the current dose unless blood pressure drops significantly.

Beta-blocker (Carvedilol): Continue at 25 mg twice daily; ensure the patient’s heart rate is stable and not too low.

SGLT2 Inhibitor (Empagliflozin 10 mg daily): Consider adding this agent for further benefit in HFrEF patients and to aid in diuresis.

Aspirin should be continued at 81 mg daily, given the patient's prior MI.

Statin therapy (Atorvastatin 40 mg nightly) should continue for secondary prevention of cardiovascular events.

Lifestyle Modifications:

Diet: Encourage a low-sodium diet (less than 2,000 mg sodium daily) and a fluid restriction if necessary, especially if the patient experiences significant fluid retention.

Exercise: Recommend mild activity as tolerated, emphasizing daily walking to improve circulation and overall fitness.

Weight management: Address weight reduction, considering the patient’s obesity and its impact on heart failure.

Smoking cessation and alcohol reduction: Encourage cessation of smoking and limiting alcohol intake, as these can exacerbate heart failure symptoms.

Monitoring & Follow-up:

Daily weight monitoring at home to assess for sudden weight gain (fluid retention).

Regular follow-up within 1-2 weeks to reassess symptoms and medication tolerability.

Frequent blood pressure and renal function checks to monitor for adverse effects from diuretics or renin-angiotensin-aldosterone system inhibitors.

Monitor for arrhythmias given the patient’s history of MI and reduced ejection fraction, possibly with Holter monitoring if indicated.

Patient Education:

Educate the patient on the importance of medication adherence, especially with ACE inhibitors, beta-blockers, diuretics, and aldosterone antagonists.

Teach the patient to recognize worsening heart failure symptoms, including sudden weight gain, increased shortness of breath, and swelling in the legs.

Dietary counseling to reduce sodium intake and improve heart failure management.

Encourage the patient to weigh themselves daily and to report a sudden weight gain of more than 2-3 pounds in one day or 5 pounds in a week to their healthcare provider.

Referral:

Cardiology follow-up in 1-2 weeks to reassess the management plan and make adjustments as necessary.

Possible referral to heart failure clinic for specialized care if symptoms do not stabilize.

Discussion:

Heart failure with reduced ejection fraction (HFrEF) is characterized by a decreased ability of the heart to pump blood, leading to fluid accumulation and symptoms such as shortness of breath, fatigue, and edema. The management of HFrEF involves medications that target the renin-angiotensin-aldosterone system (ACE inhibitors, ARBs), beta-blockers, and diuretics, as well as lifestyle modifications. The patient’s history of myocardial infarction (MI) and hypertension, along with their current symptoms and reduced ejection fraction, highlights the importance of optimizing heart failure management to prevent further decompensation and improve quality of life.

Prognosis:
With appropriate pharmacological therapy, including diuretics, ACE inhibitors, and beta-blockers, along with lifestyle changes, the patient’s symptoms can be improved, and the risk of further heart failure exacerbations can be reduced. However, the patient will need long-term monitoring and management to prevent progression of heart failure.