Optimizing HF Care: When to Consider Baroreflex Activation Therapy

Mar 13, 2025   |  Nadia Fida, MD, FACC
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A 50-year-old woman presents to the clinic with worsening fatigue, dyspnea on exertion, and peripheral edema over the previous 3 months. She has a history of hypertension and nonischemic dilated cardiomyopathy diagnosed 5 years earlier. She has come for a second opinion. She had one heart failure (HF) hospitalization this year when she was also diagnosed with coronavirus disease 2019 pneumonia. She reports significant fatigue and shortness of breath when climbing a single flight of stairs over the previous 3 months. She has no symptoms at rest and can complete household chores including cooking, making her bed, and vacuuming the carpeted floors. However, she requires frequent breaks when shopping for groceries. She is frustrated with her quality of life (QoL) and misses taking her dogs out for even a short walk down the driveway and street because she has to take breaks. She is currently managed with guideline-directed medical therapy (GDMT) for HF and a primary-prevention implantable cardioverter-defibrillator is in place. Her medications include sacubitril/valsartan 97/103 mg twice daily, carvedilol 25 mg twice daily, spironolactone 25 mg daily, empagliflozin 10 mg daily, and furosemide 40 mg daily.

Her office vital signs include heart rate 85 bpm, blood pressure (BP) 102/65 mm Hg, and oxygen saturation 98% on room air. Her clinical examination findings include normal skin color, warm to touch, jugular venous distention visible 5 cm (2 in) above the clavicle in the sitting position, normal rate and rhythm, S1, S2, no S3, soft grade 2/6 systolic murmur at the left lower sternal border, lungs clear to auscultation bilaterally, and 1+ pedal edema.

A 12-lead electrocardiogram has findings of normal sinus rhythm with QRS duration (QRSd) 90 msec, normal axis, and nonspecific ST-T changes in the anterior leads. An echocardiogram has findings of moderately dilated left ventricle (LV), LV end-diastolic diameter 6 cm, normal thickness, left ventricular ejection fraction (LVEF) 25-30%, normal right ventricular (RV) size and function (tricuspid annular plane systolic excursion 1.9 cm), moderately dilated left atrium (LA; LA volume index 46 mL/m2), right atrium normal in size, mild central mitral regurgitation, mild central tricuspid regurgitation, grade 2 diastolic dysfunction, and estimated RV systolic pressure 45 mm Hg. Doppler cardiac index is 2.1 L/min/m2.

Her laboratory study results include B-type natriuretic peptide level 560 pg/mL, serum sodium level 136 mmol/L, serum creatinine level 1.1 mg/dL, and potassium level 4.3 mmol/L.

Despite optimal GDMT and adherence to lifestyle recommendations, she reports significant limitations in her daily activities and repeated hospitalization for decompensated HF. She is seeking additional options to improve her symptoms and QoL.

Which one of the following factors makes her an appropriate candidate for baroreflex activation therapy (BAT)?

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