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

 

Pharmacotherapy Case Study: Heart Failure with Preserved Ejection Fraction (HFpEF)
Patient Profile: 75-year-old female

Subjective Data

  • Chief Complaint: “I’ve been struggling to catch my breath, especially when walking or climbing stairs. My ankles are swollen, and I feel exhausted all the time.”
  • History of Present Illness:
    • Progressive dyspnea on exertion (now after walking 10 feet) over 4 weeks.
    • Orthopnea (needs 2 pillows to sleep) and fatigue interfering with daily activities.
    • Bilateral lower extremity edema (worsening despite occasional furosemide use).
    • No chest pain, palpitations, or syncope.
  • Medical History:
    • Hypertension (25 years), type 2 diabetes (15 years), obesity (BMI 34 kg/m²).
    • Atrial fibrillation (diagnosed 3 years ago, non-adherent to anticoagulation).
    • Chronic kidney disease (CKD Stage 3, baseline creatinine 1.4 mg/dL).
  • Medications:
    • Furosemide 20 mg PRN (takes “only when legs swell”).
    • Metoprolol succinate 50 mg daily (skips doses due to dizziness).
    • No SGLT2 inhibitor, ACEI/ARB, or anticoagulant use.
  • Social History:
    • Sedentary lifestyle; diet high in processed foods and salt.
    • Smoked 1 pack/week × 20 years (quit 10 years ago).

Objective Data

  • Vitals:
    • BP: 168/94 mmHg, HR: 88 bpm (irregularly irregular).
    • RR: 22/min, SpO₂: 94% on room air, weight: 92 kg (↑4 kg in 3 weeks).
  • Physical Exam:
    • Cardiovascular: Elevated JVP (9 cm), S4 gallop, no murmurs.
    • Lungs: Bibasilar crackles.
    • Extremities: Pitting edema (2+) to mid-calves.
  • Labs:
    • BNP: 320 pg/mL (mildly elevated for HFpEF).
    • Na⁺: 138 mEq/L, K⁺: 4.5 mEq/L, Cr: 1.6 mg/dL (baseline: 1.4 mg/dL).
    • HbA1c: 8.5%, LDL: 110 mg/dL.
  • Imaging:
    • Echocardiogram: LVEF 60%, left atrial enlargement, diastolic dysfunction (E/e’ ratio: 16).
    • Chest X-ray: Mild pulmonary congestion, no cardiomegaly.
  • ECG: Atrial fibrillation with controlled ventricular rate.

Assessment

  1. Primary Diagnosis:
    • Acute decompensated HFpEF (LVEF 60% + diastolic dysfunction) with volume overload.
    • Precipitants: Uncontrolled hypertension, non-adherence to medications, obesity.
  2. Comorbidities:
    • Hypertension, type 2 diabetes, CKD Stage 3, atrial fibrillation.
  3. NYHA Class: III (marked limitation of activity).

Pharmacotherapy Plan

  1. Immediate Management:
    • Diuresis:
      • Furosemide 40 mg IV ×1 dose, then transition to oral furosemide 20 mg daily (titrate to euvolcemia; avoid overdiuresis).
    • Blood Pressure Control:
      • Initiate losartan 50 mg daily (ARB preferred for HFpEF and diabetes; monitor Cr/K⁺).
    • Rate Control:
      • Continue metoprolol succinate 50 mg daily (titrate to 100 mg as tolerated for AF and hypertension).
  2. Long-Term Guideline-Directed Therapy:
    • SGLT2 Inhibitor:
      • Dapagliflozin 10 mg daily (reduces HF hospitalizations in HFpEF and improves glycemic control).
    • Mineralocorticoid Receptor Antagonist (MRA):
      • Spironolactone 12.5 mg daily (if K⁺ <5.0 mEq/L; improves diastolic function in select HFpEF patients).
    • Anticoagulation:
      • Apixaban 5 mg BID (CHA₂DS₂-VASc score = 5; history of AF).
  3. Adjunctive Therapy:
    • Statin:
      • Atorvastatin 40 mg daily (LDL goal <70 mg/dL).
    • Diabetes Management:
      • Optimize metformin (hold if eGFR <30) and dapagliflozin.
  4. Non-Pharmacologic Interventions:
    • Structured Exercise Program: Refer to cardiac rehabilitation.
    • Diet: Sodium restriction (<2,300 mg/day), DASH diet for hypertension.
    • Weight Loss: Goal 5–10% body weight (improves diastolic function).

Monitoring

  • Daily: Weight, orthostatic BP, edema, renal function.
  • Weekly: Electrolytes (monitor for hyperkalemia with spironolactone and ARB).
  • Echocardiogram in 6 months to reassess diastolic parameters.

Patient Education

  • Medication Adherence: Use a pill organizer; emphasize dapagliflozin and anticoagulant necessity.
  • Symptom Tracking: Daily weight checks, report dyspnea/edema worsening.
  • Avoid NSAIDs and high-sodium foods (exacerbate HFpEF).

Rationale:

  • Dapagliflozin is foundational in HFpEF per recent trials (DELIVER), reducing cardiovascular death/HF hospitalization by 18%.
  • ARBs (losartan) target hypertension and may improve outcomes in HFpEF with diabetes.
  • Spironolactone is used cautiously in HFpEF with close monitoring, as some data suggest diastolic improvement.
  • Aggressive BP control and weight loss address root causes of diastolic dysfunction.
  • Anticoagulation mitigates stroke risk in AF, a common HFpEF comorbidity.

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