A 71-year-old man with heart failure with reduced ejection fraction (HFrEF; 30%) due to ischemic cardiomyopathy, hypertension, and hyperlipidemia is admitted for acute decompensated heart failure (HF). He received 3 days of intravenous furosemide and optimization of guideline-directed medical therapy (GDMT). He is now euvolemic. He reports dizziness with ambulation this morning during bedside rounds.
His blood pressure is 95/65 mm Hg and heart rate is 70 bpm. He has no elevation in jugular venous pressure (JVP) and his extremities are warm and without edema. There is no significant change in blood pressure with going from sitting to standing. Yesterday, his vital signs revealed blood pressure 105/70 mm Hg and heart rate 75 bpm; he was asymptomatic. His current medication regimen includes aspirin 81 mg daily, metoprolol succinate 100 mg daily, sacubitril/valsartan 49/51 mg BID, spironolactone 25 mg daily, dapagliflozin 10 mg daily, and furosemide 20 mg daily.
His renal function is stable (creatinine level 0.89 mg/dL) and electrolyte levels are within the reference ranges. N-terminal pro–B-type natriuretic peptide level has improved from 7,522 g/dL on admission to 3,406 g/dL.
The clinician decides to decrease the doses of sacubitril/valsartan and spironolactone, and to repeat vital sign readings tomorrow.
The correct answer is: Fiction
This is a typical patient with HFrEF who has been diuresed during an HF exacerbation and now appears euvolemic on clinical examination. He is on moderate doses of GDMT and is nearing discharge. He is experiencing mild symptoms of dizziness that could be consistent with hypotension.
It is important to recognize the clinical findings that suggest intolerance to GDMT due to worsening HF. These findings include worsening renal function, rising/failure to fall in natriuretic peptide levels, elevation in liver enzyme levels, and clinical signs of hypoperfusion such as low blood pressure, poor mentation, cold extremities, and rising JVP. In this case, the plan should not be to discontinue or decrease the dosage of medications that improve HF outcomes, as all his objective measures of HF compensation have improved. Several landmark studies have shown improved outcomes for patients with HFrEF on guideline-directed beta blockers,1-3 angiotensin receptor–neprilysin inhibitors,4,5 mineralocorticoid-receptor antagonists,6 and sodium-glucose cotransporter-2 inhibitors (SGLT2i).7,8 These medications should be initiated and/or maintained prior to discharge from an HF hospitalization.9
A preferable option for this scenario would be to stagger the dosing schedule of the HF medications or reduce the loop diuretic to an as-needed schedule. For example, the beta-blocker could be taken in the evening along with the SGLT2i instead of all the daily medications being taken in the morning. Given the stable trend in vital signs and laboratory studies, this patient should be able to tolerate the current regimen, with possible uptitration of sacubitril/valsartan in the future once he has equilibrated to a new dosing schedule.
Educational grant support provided by: Boehringer Ingelheim Pharmaceuticals Inc. (BIPI) and Lilly USA, LLC (Lilly). To visit the course page for the Heart Failure & SGLT2is: The New Pillar in Care grant,click here!
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Effect of metoprolol CR/XL in chronic heart failure: metoprolol CR/XL randomised intervention trial in congestive heart failure (MERIT-HF). Lancet 1999;353:2001-7.
The cardiac insufficiency bisoprolol study II (CIBIS-II): a randomised trial. Lancet 1999;353:9-13.
McMurray JJ, Packer M, Desai AS, et al. Angiotensin-neprilysin inhibition versus enalapril in heart failure. N Engl J Med 2014;37:993-1004.
Velazquez EJ, Morrow DA, DeVore AD, et al. Angiotensin-neprilysin inhibition in acute decompensated heart failure. N Engl J Med 2019;380:539-48.
Pitt B, Zannad F, Remme WJ, et al. The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators. N Engl J Med 1999;341:709-17.
McMurray JJV, Solomon SD, Inzucchi SE, et al. Dapagliflozin in patients with heart failure and reduced ejection fraction. N Engl J Med 2019;381:1995-2008.
Packer M, Anker SD, Butler J, et al. Cardiovascular and renal outcomes with empagliflozin in heart failure. N Engl J Med 2020;383:1413-24.
Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2022;79:e263-e421.