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After completing this case study, the reader should be able to:

  • Recognize the signs and symptoms of heart failure.

  • Develop a pharmacotherapeutic plan for treatment of heart failure with reduced ejection fraction (HFrEF).

  • Outline a monitoring plan for heart failure that includes both clinical and laboratory parameters.


Chief Complaint

“I’ve been more short of breath lately. I can’t seem to walk as far as I used to, and either my feet are growing or my shoes are shrinking!”


Rosemary Quincy is a 68-year-old African-American female who presents to her family medicine physician for evaluation of her shortness of breath and increased swelling in her lower extremities. She reports that her shortness of breath has been gradually increasing over the past 4 days. She has noticed that her shortness of breath is particularly worse when she is lying in bed at night, and she has to prop her head up with three pillows in order to sleep. She also reports exertional dyspnea that is usual for her, but especially worse over the past couple of days.


  • Hypertension × 20 years

  • CHD with history of MI in 2005 (PCI performed and bare metal stents placed in LAD and RCA)

  • Heart failure (NYHA FC III)

  • Type 2 DM × 25 years

  • Atrial fibrillation

  • COPD (GOLD 3, Group D)

  • CKD (Stage 4)


Father died of lung cancer at age 71, mother died of MI at age 73.


Reports occasional alcohol intake. States she has been trying to follow her low-cholesterol and low-sodium diet. Former smoker (35 pack-year history; quit approximately 10 years ago).


  • Valsartan 160 mg PO BID

  • Furosemide 40 mg PO BID

  • Warfarin 2.5 mg PO once daily

  • Carvedilol 3.125 mg PO BID

  • Pioglitazone 30 mg PO once daily

  • Glimepiride 2 mg PO once daily

  • Potassium chloride 20 mEq PO once daily

  • Atorvastatin 40 mg PO once daily

  • Aspirin 81 mg PO once daily

  • Albuterol MDI, two inhalations by mouth q 4–6 hours PRN shortness of breath

  • Tiotropium DPI 18 mcg, one inhalation by mouth daily

  • Fluticasone/salmeterol DPI 250 mcg/50 mcg, one inhalation by mouth BID


Lisinopril (cough).


Approximate 7-kg weight gain over the past week. No fever or chills. Denies any recent chest pain, palpitations, or dizziness. Reports worsening shortness of breath with exertion and three-pillow orthopnea. Describes a chronic, dry (nonproductive), hacking cough, which she describes as usual ...

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