Case Discussion. 18 th Annual UCSD Heart Failure Symposium

Transcription

1 Case Discussion 18 th Annual UCSD Heart Failure Symposium

2 In your office today is a returning patient and an eager-to-please 3 rd year medical student. You review HF s history as the student is in the room. HF is a 75 yr WM man who was first received the diagnosis of HF with reduced EF (HF-rEF) and non-ischemic CMY during a hospitalization 4 years ago. His only risk factor for HF was HTN. Initial LVEF was 27%. You had initiated GDMT and up titrated the Rx s over time to reach target dose carvedilol 25 mg BID, lisinopril 20 mg qd, spironolactone 25 mg qd. He has also been on furosemide 40 mg qd and ASA 81 mg qd. He has no other major co-morbid conditions or bad habits and has been compliant with your care plans.

3 After 4 months on the above Rx s, a repeat echo demonstrated that his EF had improved to 33%. His EKG QRS was narrow. You appropriately referred him for ICD implantation without CRT. He has not had a single ICD shock. He has a semi-active lifestyle (walks golf course, plays singles tennis) and at worst has had NYHA II symptoms for 3 years or so. BP is 142/86, HR 68. BMI 29. His CBC, renal and thyroid function are normal, A1C is 6%, and his lipid profile w/in goal range. His pro BNP is On his last visit you ordered a repeat ECHO as he has not had one in 2 years.

4 HF is here for follow up of the echo results. His exam is benign. His EF is now 48%, LV size is at upper limit normal, there was mild LAE, mild diastolic dysfunction and no significant valvular abnls. The medical student is now ready to present and asks you which is the best way to summarize the patient. v This is our 75 yr old WM with HF-pEF v This is our 75 yr old WM with HF-mEF v This is our 75 yr old WM with HF-rEF, improved Why does it matter? Isn t this just a distinction without a difference?

5 The student does a reasonably good job in developing the problem list with your guidance but wants to be sure you know she read about the newest heart failure therapies. She boldy states.. I think we should change his Lisinopril to Entresto, right? YEA? NAY?

6 A few months later you learn that HF was hospitalized for 2 days with symptomatic new onset A-Fib with RVR. He was cardiovertedafter a TEE showed no evidence of a LA thrombus. His LV function was not changed. He had no decompensation of HF. Thyroid fxn was normal. HF flatly refused to take warfarin, and was started on a NOAC. He is back in your office today for follow up and wants to stop the NOAC as he has had recurrent nosebleeds and bleeding hemorrhoids. Both frighten and embarrass him. HR 66 reg, BP 122/78. The same medical student is rotating through your office again.

7 The student learns that the patient blames the episode of atrial fibrillation on having decided to try out his grandson s now legal marijuana. He hasn t had any symptoms or palpitations since (2 months have passed). His EKG shows NSR and is unchanged from prior. The student correctly calculates his CHA2DS2-VASc score as 4 but asks: v Since the AFIB was just one time, can t we just switch him back to aspirin at 325 mg? Or perhaps Clopidogrel? v What about convincing him to try coumadin instead or even a different NOAC? v What about the Watchman device?

8 Six months hence, HF noted fatigue, exertional intolerance and was requiring a higher dose of furosemide (40 mg BID) for relief of DOE. Your workup revealed that his LVEF has declined to 33% again. Stress imaging was negative for ischemia. His EKG has a QRS of 110 ms, LAE. Labs: Creat1.1, and NT pro-bnp 2450, otherwise unremarkable. As luck? would have it, the same student is back in your office, this time as a 4 th year subintern, and states even more confidently than before

9 I think we should change his Lisinopril to Entresto, NOW, right? YEA? NAY? To keep her grounded you ask.. What do you have to keep in mind when switching from an ACE inhibitor to Valsartan-Sacubutril??

10 AFTER LUNCH!!