Chapter 15: Heart Failure with Reduced Ejection Fraction

PATIENT PRESENTATION

Chief Complaint

“I’m breathing more easily and my legs are much less swollen.”

History of Present Illness

AK is a 52-year-old white male newly diagnosed with heart failure with reduced ejection fraction (HFrEF) after presenting to the emergency department to evaluate dyspnea that has increased in severity over approximately 5 days. AK had noted dyspnea on exertion when performing routine activities of daily living, three-pillow orthopnea, nonproductive cough accompanied by general malaise, 4 kg weight gain, and +2 bilateral pitting edema with diminished pedal pulses upon presentation. He denied fever, chest pain, and hemoptysis. Additionally, he denied abdominal pain, nausea/vomiting, or diarrhea.

AK was subsequently admitted to a telemetry unit. His brain natriuretic peptide (BNP) was noted to be severely elevated (1305 pg/mL) and echocardiogram revealed left ventricular dysfunction with ejection fraction (EF) 25% to 30%. He was aggressively diuresed per protocol to dry weight. After a total of 3 days of acute care, he has stabilized with disposition to discharge home to self-care.

Past Medical History

Type 2 diabetes mellitus (T2DM)

Hypertension (HTN)

Hyperlipidemia (HLD)

Coronary artery disease (CAD)

Myocardial infarction (MI) in 2017

Surgical History

Placement of drug-eluting stents (DES) × 3 in 2017

Family History

Father: CAD

Mother: T2DM

Social History

Widowed, retired school maintenance supervisor.

Lives independently but has three children who are supportive and visit frequently.

Denies tobacco use.

Drinks 4 to 5 alcoholic beverages on weekends.

Immunization

Up to date

Insurance

Medicaid

Allergies

No known drug allergies

Home Medications Prior to Admission

• Aspirin 81 mg PO daily

• Dapagliflozin 10 mg PO daily

• Lisinopril 10 mg PO daily

• Metformin 1000 mg PO bid

• Nitroglycerin 0.4 mg SL PRN chest pain (CP). May repeat in 5 minutes if CP does not subside. Do not exceed 3 tablets in 15 minutes.

• Propranolol 40 mg PO bid

• Rosiglitazone 4 mg PO daily

• Semaglutide 0.5 mg SQ q week

• Simvastatin 20 mg PO qHS

Inpatient Medications

• Aspirin 81 mg PO daily

• Insulin aspart per sliding scale

• Furosemide 20 mg PO daily

• Lisinopril 10 mg PO daily

• Nitroglycerin 0.4 mg SL PRN CP. May repeat in 5 minutes if CP does not subside. Do not exceed 3 tablets in 15 minutes.

• Propranolol 40 mg PO bid

• Atorvastatin 10 mg PO qHS

Physical Examination