|An 82-year-old woman with a distant history of myocardial infarction is referred to your outpatient clinic several months after a first hospitalization for acute decompensated HF. In the hospital, she was diagnosed with an ischemic cardiomyopathy and HFrEF. Her LV ejection fraction is 30%. She has been experiencing fatigue for the past several years. On examination, she appears euvolemic. Her current medication regimen includes metoprolol XL 100 mg daily, lisinopril 5 mg daily, and spironolactone 25 mg daily. She does not have a defibrillator. How should she be treated next?|
|Patient A||Patient B|
|Medical/Surgical Domain: In addition to cardiac history noted above, patient has diabetes, hypertension, and stage 2 CKD. Her weight has been stable over the last year with normal appetite.||Medical/Surgical Domain: In addition to cardiac history noted above, patient has diabetes, hypertension, stage 3 CKD, COPD, peptic ulcer disease, and a history of stroke with minimal residual neurological deficits. She has lost 10 pounds over the last year and has poor appetite.|
|Mental Status/Emotions/Coping Domain: No history of depression. The Mini-Cog is normal.||Mental Status/Emotions/Coping Domain: Reports feeling sad and lonely most days of the week. The Mini-Cog is positive suggesting cognitive impairment.|
|Physical Function Domain: She is able to get dressed on her own with some dyspnea. Her measured gait speed in your clinic is 1.1 m/s. She has a firm handshake.||Physical Function Domain: She is able to get dressed on her own with some dyspnea. Her measured gait speed in your clinic is 0.6 m/s. She has a weak handshake, and reports fatigue with limitations in taking the stairs and walking.|
|Living Environment Domain: Living alone in own home and manages her own medications. Adult children live in same city within driving distance.||Living Environment Domain: Living in own home. Her daughter sets up medications for her. Adult children live in same city within driving distance.|
|Considerations: Focus on optimizing ACC/AHA/HFSA guideline-directed medical therapy, including increasing ACEI or switching from ACEI to ARNI. Consider a “trial” of reduced dose of BB in the setting of excessive fatigue. Consider more intensive screening for depression as a further contributor. Spironolactone was introduced before ACEI has been maximized, adding to polypharmacy and risk of hyperkalemia, and requiring more frequent laboratory monitoring. Consider temporarily eliminating spironolactone and reintroducing it once ACEI or ARNI have been maximized if patient remains symptomatic. Discuss preferences for care when her heart or breathing stop and if she would want an attempt at resuscitation. Discuss whether she is willing to have an implantable device, then refer for ICD evaluation for prevention of sudden cardiac death. Discuss decision-making and identify preferred surrogate decision-maker. Encourage patient to fill out advance directive forms, including health care power of attorney and living will.||Considerations: Patient is frail, likely malnourished, and has cognitive impairment. Consider reducing dose of BB in setting of fatigue, and avoid hypotension that may exacerbate risk of falls at home. Spironolactone was introduced before ACEI has been maximized, adding to polypharmacy and risk of hyperkalemia, and requiring more frequent laboratory monitoring. Consider temporarily eliminating spironolactone and reintroducing it once ACEI has been maximized if patient remains symptomatic. Convene family meeting to discuss goals of care, and preferences regarding ICD implantation in setting of the patient’s guarded prognosis. Emphasize that cognitive impairment is associated with medication self-management errors, and family members should oversee distribution of medications into pill box. Consider referral for home care skilled nursing visit or house calls physician or advanced practice practitioner visit (team care), and consultation with a dietitian. See patient in clinic more frequently if possible, or via more frequent telephone or telemedicine/video connection. Encourage engagement of community family and friend network. Patient is not ready for hospice referral, but consider a 1-time outpatient consultation with a palliative medicine clinician for introductory purposes.|
ACC = American College of Cardiology; ACEI = angiotensin-converting enzyme inhibitor; AHA = American Heart Association; ARNI = angiotensin receptor neprilysin inhibitor; BB = beta-blocker; CKD = chronic kidney disease; COPD = chronic obstructive pulmonary disease; HF = heart failure; HFrEF = heart failure with reduced ejection fraction; HFSA = Heart Failure Society of America; ICD = implantable cardioverter-defibrillator; LV = left ventricular.