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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 guideline-directed medical therapy (GDMT) in HFpEF when indicated.

PATIENT PRESENTATION

Chief Complaint

“Why can’t we get my weight stabilized?”

HPI

Lawrence Smith is a 67-year-old man who presents to the ED with shortness of breath and bilateral lower extremity edema. He reports his symptoms started approximately 3 weeks ago. He noted that he was gaining about 1–2 lb daily and gained approximately 25 lb of weight over the month prior to admission. He attempted to use his albuterol/ipratropium MDI for relief of his shortness of breath symptoms at home without improvement. As his symptoms of edema and shortness of breath worsened, he called his primary care physician, who increased his furosemide dose over the phone to 80 mg twice daily more than 1 week ago. 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 minimal improvement in his symptoms and then admitted to the medicine service for further evaluation and management.

PMH

CAD (s/p STEMI 10 years ago)

COPD × 5 years

HFpEF × 6 years (last hospitalization 4 months ago)

Dyslipidemia × 15 years

HTN × 25 years

Type 2 DM × 5 years

FH

Father is alive at age 88 with type 2 DM; mother is alive at age 87 and has HTN and dyslipidemia; two brothers (age 60 and 64) are alive and both have type 2 DM and HTN.

SH

History of tobacco use (40 pack-year history), but quit 5 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

Clopidogrel 75 mg PO daily

Lisinopril 40 mg PO daily

Carvedilol 12.5 mg PO BID

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

Amlodipine 5 mg PO daily

Metformin 1000 mg PO BID

Nitroglycerin 0.4 mg SL ...

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