Chapter 16: Heart Failure with Preserved Ejection Fraction: A Balancing Act Level II

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LEARNING OBJECTIVES

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

• Recognize the signs and symptoms of heart failure with preserved ejection fraction (HFpEF).

• Develop a pharmacotherapeutic plan for treatment of HFpEF.

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

• Initiate, titrate, and monitor β-adrenergic blocker, calcium channel blocker, angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, aldosterone antagonist and diuretic therapy in HFpEF when indicated.

PATIENT PRESENTATION

Chief Complaint

“Why do I keep gaining all this weight?”

HPI

Lawrence Smith is a 62-year-old man who presents to the ED with shortness of breath and lower extremity edema. He reports his symptoms started approximately 1–1.5 weeks ago. He noted that he was gaining about 2 lb daily and gained approximately 15 lb of weight over the week prior to admission. He attempted to use his albuterol/ipratropium MDI for relief of symptoms at home without improvement. As his symptoms worsened, he called his primary care physician, who increased his furosemide dose over the phone to 80 mg twice daily. In the ED he was noted to be hypoxic with an increased oxygen need from 2 to 4 L by nasal cannula. He was given one dose of IV furosemide 80 mg with improvement and then admitted to the medicine service for further evaluation and management.

PMH

• CAD (s/p STEMI 6 years ago)

• COPD × 3 years

• HFpEF × 4 years (last hospitalization 6 months ago)

• Dyslipidemia × 10 years

• HTN × 20 years

• Type 2 DM × 3 years

FH

Father is alive at age 86 with type 2 DM; mother is alive at age 84 and has HTN and dyslipidemia; two brothers (age 56 and 60) alive and both have type 2 DM and HTN.

SH

History of tobacco use (30 pack-year history), but quit 3 years ago. Denies any alcohol or substance abuse. Lives alone.

Meds

• Albuterol/ipratropium MDI, two puffs inhaled Q 6 H PRN

• Aspirin 81 mg PO daily

• Lisinopril 40 mg PO daily

• Carvedilol 12.5 mg PO BID

• Furosemide 80 mg PO BID (previously 40 mg PO BID)

• Isosorbide mononitrate ER 30 mg PO Q AM

• Metformin 500 mg PO BID

• Nitroglycerin 0.4 mg SL q 5 minutes PRN chest pain

• Potassium chloride 20 mEq PO BID

• Rosuvastatin 20 mg PO daily

All

NKDA

ROS

Gen

Patient reports a recent 15-lb weight gain over the past ...