Chapter 1. Chronic Heart Failure
KW is a 53-year-old man with HF (NYHA class I) receiving furosemide 40 mg twice daily, lisinopril 10 mg daily, metoprolol succinate 50 mg daily, digoxin 0.125 mg daily, and spironolactone 25 mg daily. During a routine clinic visit today, pertinent findings include: BP 120/80 mm Hg, HR 70 bpm, RR 14 breaths/min, potassium 5.1 mmol/L, BUN 35 mg/dL, and creatinine 1.2 mg/dL (baseline). Which of the following is the most appropriate change to optimize KW’s medical regimen?
a. Increase ACE inhibitor dose
b. Increase β-blocker dose
d. Increase spironolactone dose
Answer b is correct. For HF management, ACE inhibitor and β-blocker therapy should be titrated to target doses associated with improved outcomes in clinical trials. This patient has adequate BP and HR to further titrate β-blocker therapy.
Answer a is incorrect. ACE inhibitors are associated with dose-related hyperkalemia and this patient already has borderline high serum potassium.
Answer c is incorrect. Although the patient’s HR is 70 bpm or more, β-blocker therapy is not yet at target dose and the patient does not have any evidence of intolerance that might preclude dose up-titration. Because β-blockers improve mortality (whereas ivabradine primarily reduces hospitalizations), ivabradine should be reserved for patients who remain symptomatic despite maximally tolerated β-blocker therapy.
Answer d is incorrect. Aldosterone antagonists such as spironolactone are associated with hyperkalemia. Thus, the spironolactone dose should not be increased and may even need to be reduced to 12.5 mg daily if hyperkalemia persists or worsens.
JC is a 64-year-old African American man with recently diagnosed HFrEF presenting with a 2-week history of SOB which limits his normal daily activities and increased lower extremity edema. His weight has recently increased by 10 pounds. His physical examination is notable for BP 148/72 mm Hg, HR 68 bpm, RR 24 breaths/min rales, and 3+ lower extremity edema. Pertinent laboratory values include: sodium 138 mmol/L, potassium 5.4 mmol/L, BUN 35 mg/dL, and creatinine 0.9 mg/dL. Past medical history is significant for HTN and COPD. Current medications include lisinopril 20 mg daily, metoprolol XL 50 mg daily, and salmeterol/fluticasone 250/50 two puffs twice daily. In addition to counseling on salt and fluid restriction, which of the following pharmacologic options is most appropriate for managing JC’s fluid overload?
a. Initiate hydrochlorothiazide 50 mg daily.
b. Initiate furosemide 40 mg twice daily.
c. Initiate metolazone 2.5 mg daily.
d. Initiate spironolactone 25 mg daily.