Pharmacotherapy Case Study: Heart Failure with Reduced Ejection Fraction by Dr. Nehad Jaser

 

Pharmacotherapy Case Study: Heart Failure with Reduced Ejection Fraction (HFrEF)
Patient Profile: 68-year-old male

Subjective Data

  • Chief Complaint: “I’ve been short of breath for weeks, even when resting. My legs are swollen, and I can’t sleep lying flat.”
  • History of Present Illness:
    • Progressive dyspnea on exertion (now present at rest) over 3 weeks.
    • Orthopnea (needs 3 pillows to sleep) and paroxysmal nocturnal dyspnea ×2 episodes.
    • Bilateral lower extremity edema (worsening despite daily furosemide).
    • Fatigue and reduced exercise tolerance (unable to walk 1 block).
  • Medical History:
    • Hypertension (20 years), type 2 diabetes (10 years), myocardial infarction (5 years ago).
    • Non-adherent to medications for 6 months due to cost concerns.
  • Medications:
    • Furosemide 40 mg daily (takes intermittently).
    • Metoprolol tartrate 25 mg BID (skips doses due to fatigue).
    • No ACEI/ARB/ARNI or SGLT2 inhibitor use.
  • Social History:
    • Former smoker (1 pack/day × 30 years, quit 5 years ago).
    • Sedentary lifestyle; diet high in processed foods and salt.

Objective Data

  • Vitals:
    • BP: 150/90 mmHg, HR: 110 bpm (irregularly irregular).
    • RR: 24/min, SpO₂: 92% on room air, weight: 89 kg (↑6 kg in 2 weeks).
  • Physical Exam:
    • Cardiovascular: Elevated JVP (8 cm), S3 gallop, bilateral crackles up to mid-lung fields.
    • Extremities: Pitting edema (3+) to knees.
    • Abdomen: Hepatomegaly with hepatojugular reflux.
  • Labs:
    • BNP: 850 pg/mL (elevated).
    • Na⁺: 135 mEq/L, K⁺: 4.2 mEq/L, Cr: 1.5 mg/dL (baseline: 1.1 mg/dL).
    • HbA1c: 8.2%, LDL: 130 mg/dL.
  • Imaging:
    • Echocardiogram: LVEF 30%, global hypokinesis, dilated left ventricle.
    • Chest X-ray: Pulmonary congestion, cardiomegaly.
  • ECG: Atrial fibrillation with rapid ventricular response.

Assessment

  1. Primary Diagnosis:
    • Acute decompensated HFrEF (LVEF 30%) with volume overload.
    • Precipitants: Non-adherence to medications, uncontrolled hypertension, atrial fibrillation.
  2. Comorbidities:
    • Hypertension, type 2 diabetes, CKD Stage 3a.
  3. NYHA Class: IV (symptoms at rest).

Pharmacotherapy Plan

  1. Immediate Management:
    • Diuresis:
      • Furosemide IV 40 mg bolus, then 10 mg/hr infusion (titrate to urine output ≥200 mL/hr).
      • Monitor electrolytes and renal function daily.
    • Rate Control for AF:
      • Metoprolol tartrate 5 mg IV every 15 minutes ×3 doses (if no contraindications).
      • Transition to oral carvedilol 3.125 mg BID once stable (preferred beta-blocker for HFrEF).
    • Afterload Reduction:
      • Nitroglycerin IV infusion (start at 10 mcg/min) if BP remains >120/80 mmHg.
  2. Long-Term Guideline-Directed Medical Therapy (GDMT):
    • ARNI (Sacubitril/Valsartan):
      • Start 24/26 mg BID after 36-hour washout from ACEI/ARB (if SBP >100 mmHg).
      • Titrate to 97/103 mg BID over 2–4 weeks.
    • Beta-Blocker:
      • Switch to carvedilol 3.125 mg BID, titrate to target 25 mg BID as tolerated.
    • SGLT2 Inhibitor:
      • Empagliflozin 10 mg daily (reduces HF hospitalization, improves glycemic control).
    • MRA (Mineralocorticoid Receptor Antagonist):
      • Spironolactone 25 mg daily (if K⁺ <5.0 mEq/L and Cr <2.5 mg/dL).
    • Discontinue Metoprolol Tartrate (less effective in HFrEF vs. carvedilol).
  3. Adjunctive Therapy:
    • Anticoagulation:
      • Apixaban 5 mg BID (for atrial fibrillation, CHA₂DS₂-VASc score = 4).
    • Statin:
      • Atorvastatin 40 mg daily (LDL goal <70 mg/dL).
  4. Non-Pharmacologic Interventions:
    • Low-sodium diet (<2 g/day), fluid restriction (<2 L/day).
    • Cardiac rehabilitation referral post-stabilization.

Monitoring

  • Daily: Weight, urine output, electrolytes, renal function.
  • Weekly: BP, HR, symptoms (dyspnea, edema).
  • Echocardiogram in 3 months to reassess LVEF.

Patient Education

  • Medication Adherence: Use pillbox; emphasize sacubitril/valsartan and SGLT2 inhibitor benefits.
  • Symptom Tracking: Daily weight, report weight gain >2 kg in 3 days.
  • Avoid NSAIDs (worsen HF) and high-sodium foods.

Rationale:

  • Sacubitril/Valsartan reduces mortality in HFrEF vs. ACEI.
  • Carvedilol and spironolactone improve survival and reverse remodeling.
  • SGLT2 inhibitors (e.g., empagliflozin) reduce HF hospitalizations regardless of diabetes status.
  • Aggressive diuresis addresses acute volume overload, while GDMT optimizes long-term outcomes.

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