Pharmacotherapy Case Study 6: Heart Failure with Preserved Ejection Fraction By Dr. Nehad Ahmed

 

Chief Complaint:

The patient presents with complaints of increasing shortness of breath on exertion, fatigue, and swelling in the lower extremities, which have progressively worsened over the past two weeks. The patient also reports waking up at night feeling short of breath, which improves after sitting up.

Subjective Data:

History of Present Illness (HPI):
The patient reports progressively worsening shortness of breath, particularly when walking longer distances or climbing stairs. This has been occurring over the past two weeks, and the patient now finds it difficult to perform activities such as walking around the house or shopping. The patient also notes increasing fatigue, even with minimal activity, and waking up at night feeling short of breath, which is relieved by sitting up in bed. There is no chest pain, but the patient has a dry cough, especially at night, which has been interfering with sleep. Bilateral swelling of the lower legs has also been noted, especially by the end of the day.

Past Medical History (PMH):

Heart failure with preserved ejection fraction (HFpEF), diagnosed 1 year ago

Hypertension (diagnosed 15 years ago)

Type 2 diabetes mellitus

Obesity (BMI 32 kg/m²)

Hyperlipidemia

Chronic kidney disease (stage 1, stable)

 

Medications:

Lisinopril 20 mg daily

Amlodipine 5 mg daily

Furosemide 40 mg daily

Metformin 500 mg twice daily

Atorvastatin 40 mg nightly

Spironolactone 25 mg daily

Aspirin 81 mg daily

Allergies:

No known drug allergies.

Family History:

Father with heart disease and hypertension

Mother with a history of stroke

No significant family history of heart failure or arrhythmias.

Social History:

Non-smoker

Occasional alcohol use (1-2 drinks per week)

Sedentary lifestyle with no regular physical activity

Diet high in processed foods and low in fruits and vegetables

Increased stress due to work and family-related issues

Review of Systems:

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

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

Respiratory: Shortness of breath, cough, 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: 138/86 mmHg

Heart Rate: 84 bpm

Respiratory Rate: 20 breaths/min

Temperature: 36.7°C

Oxygen Saturation: 96% on room air

Weight: 92 kg (BMI 32 kg/m²)

Height: 168 cm

Physical Exam:

General: Overweight, alert, in mild distress due to shortness of breath.

Cardiovascular:

Regular rhythm, no murmurs or gallops.

Bilateral pitting edema in the lower extremities (2+ pitting), more prominent at the end of the day.

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

Respiratory:

Bilateral crackles in the lower lung fields, no wheezing or signs of active infection.

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 141 mEq/L, Potassium 4.3 mEq/L

Creatinine: 0.9 mg/dL (stable)

Blood Glucose: 120 mg/dL (fasting)

B-type Natriuretic Peptide (BNP): 1,200 pg/mL (elevated, consistent with heart failure)

Hemoglobin A1c: 7.5%

Lipid Profile:

Total Cholesterol: 225 mg/dL

LDL: 145 mg/dL

HDL: 40 mg/dL

Triglycerides: 170 mg/dL

Electrocardiogram (ECG):

Sinus rhythm, heart rate of 84 bpm, no evidence of ischemia or arrhythmias.

Normal intervals and axis.

Echocardiogram:

Left Ventricular Ejection Fraction (LVEF): 55% (preserved ejection fraction)

Left atrial enlargement and mild diastolic dysfunction.

Mild mitral regurgitation, no significant valvular disease.

Normal left ventricular end-diastolic pressure (LVEDP).

Chest X-ray:

Mild bilateral pleural effusions, no acute consolidation or pneumothorax.

Mild cardiomegaly.

Assessment:

The patient presents with symptoms consistent with Heart Failure with Preserved Ejection Fraction (HFpEF). This is characterized by a preserved ejection fraction (55% on echocardiogram) but with evidence of heart failure symptoms such as shortness of breath, fatigue, bilateral lower extremity edema, and elevated BNP. The patient's echocardiogram and BNP support the diagnosis of HFpEF. The condition is often associated with comorbidities such as hypertension, obesity, and diabetes, all of which the patient has. The patient also has chronic kidney disease, which may complicate management due to its impact on fluid balance and diuretic use.

Key issues:

Fluid retention: Bilateral lower extremity edema, mild pleural effusions, and elevated BNP levels suggest fluid overload.

Elevated blood pressure: The patient’s blood pressure is above target levels for heart failure management, potentially contributing to left ventricular diastolic dysfunction.

Diabetes and obesity: Both contribute to worsening heart failure outcomes and need close management.

Renal function: Stable, but regular monitoring is necessary due to the use of diuretics and other heart failure medications.

Plan:

Immediate Management:

Diuretics: Continue furosemide 40 mg daily. Adjust dose as needed to manage edema and fluid overload. Monitor for electrolyte imbalances, especially potassium.

Consider adding bumetanide if diuretic resistance develops, starting at 0.5 mg daily.

Pharmacotherapy Adjustments:

ACE Inhibitor (Lisinopril): Continue 20 mg daily, as ACE inhibitors are beneficial in reducing hospitalization and symptoms in HFpEF patients.

Amlodipine (Calcium Channel Blocker): Continue at 5 mg daily to help manage blood pressure and control any symptoms of vasoconstriction.

Spironolactone (Aldosterone Antagonist): Continue 25 mg daily for its benefits in reducing fluid retention and improving outcomes in HFpEF. Monitor potassium levels.

Beta-blocker (if not already initiated): Consider starting a beta-blocker, such as metoprolol succinate, to reduce heart rate and improve diastolic function, particularly if the patient has symptoms of elevated heart rate or arrhythmias.

Lifestyle Modifications:

Diet: Encourage a low-sodium diet (less than 2,000 mg per day) to help manage fluid retention.

Fluid Restriction: Consider restricting fluid intake to 1.5-2 liters per day if significant fluid retention is observed.

Weight management: Address obesity with a referral to a nutritionist for personalized weight loss strategies.

Exercise: Recommend low-impact aerobic exercise (such as walking) as tolerated to improve cardiovascular fitness and manage weight.

Monitoring & Follow-up:

Frequent blood pressure monitoring: Aim for a target BP of <130/80 mmHg.

Daily weight monitoring to assess for sudden weight gain indicating fluid retention.

Kidney function and electrolytes: Monitor creatinine and potassium levels, particularly with diuretics and aldosterone antagonists.

Follow-up appointment in 2 weeks to reassess symptoms and adjust medications as needed.

Echocardiogram follow-up in 6 months to reassess heart function and monitor diastolic function.

Patient Education:

Educate the patient on the importance of medication adherence, particularly diuretics, ACE inhibitors, and aldosterone antagonists.

Teach the patient to recognize worsening symptoms such as sudden weight gain, increased shortness of breath, or swelling in the legs.

Discuss the importance of limiting sodium intake and fluid intake as appropriate to manage heart failure.

Encourage smoking cessation (if applicable) and alcohol reduction.

Exercise: Promote physical activity tailored to the patient’s ability and symptom tolerance.

Referral:

Consider cardiology referral for advanced heart failure management if symptoms persist or worsen.

Endocrinology referral if diabetes management becomes more complex in relation to heart failure therapy.

Discussion:

Heart failure with preserved ejection fraction (HFpEF) is a complex condition often seen in patients with comorbidities such as hypertension, obesity, and diabetes. Unlike heart failure with reduced ejection fraction (HFrEF), where the heart’s ability to pump blood is impaired, HFpEF is characterized by impaired ventricular filling and relaxation, leading to symptoms of heart failure despite a normal or preserved ejection fraction.

The management of HFpEF focuses on symptom control (fluid overload) and addressing underlying conditions such as hypertension, diabetes, and obesity. Diuretics remain a mainstay for managing fluid retention, while medications like ACE inhibitors and aldosterone antagonists can improve outcomes. Lifestyle modifications, particularly in terms of diet and exercise, are critical to preventing disease progression.

Prognosis:
With appropriate pharmacologic and lifestyle interventions, symptoms of HFpEF can often be managed, though the disease may progress over time. Close monitoring and treatment of comorbid conditions are essential to improving quality of life and preventing hospitalizations. Regular follow-up is needed to ensure effective symptom control and minimize the risk of heart failure exacerbations.