Improving Outcomes for Patients with HFrEF and T2DM

A 61-year-old man who has been seeing you in clinic for the last 3 years for relatively stable heart failure with reduced ejection fraction (HFrEF) presents for a planned follow up with a repeat echo. You saw him approximately 6 months ago and uptitrated his furosemide in view of some paroxysmal nocturnal dyspnea.

Background history includes the following:

  • HFrEF:
    • ICD inserted 4 years ago (primary prevention)
    • Echocardiogram (1 month ago): left ventricular ejection fraction (LVEF) 32%, unchanged. Mild mitral regurgitation, normal right ventricular function.
  • Coronary artery disease:
    • Myocardial infarction i 2012: Percutaneous coronary intervention to left anterior descending artery, mild diffuse disease elsewhere.
  • Type 2 diabetes mellitus
  • Hypertension

Current medications are:

  • Metformin 1g once daily
  • Sacubitril/valsartan 97/103mg
  • Bisoprolol 10mg once daily
  • Spironolactone 25mg once daily
  • Atorvastatin 80mg once daily
  • Aspirin 81 mg once daily
  • Furosemide 40mg twice daily

Labs and investigations performed over the last 3 months demonstrate:

  • HbA1c 7.1%
  • eGFR 65mL/min/m2
  • ECG: 1st degree HB (PR duration 130ms), normal QRS (duration 115ms)

His blood pressure today is 115/80 mm Hg, and his heart rate (HR) is 60 beats per minute. He has pedal edema bilaterally at the ankles but otherwise appears euvolemic. He continues to have NYHA II symptoms.

What is the next most important change in his cardiovascular management to improve his overall outlook?

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