A 74-year-old man with long-standing ischemic cardiomyopathy and heart failure with reduced ejection fraction (HFrEF) status post cardiac resynchronization therapy with defibrillator (CRT-D) implantation presents for follow-up. He is currently taking guideline-directed medical therapy (GDMT), including a heart failure (HF)–specific beta-blocker, renin-angiotensin-aldosterone system inhibitor, mineralocorticoid-receptor antagonist, and sodium-glucose cotransporter-2 inhibitor. However, his GDMT doses were recently reduced because of symptomatic hypotension. Over the past year, he has experienced worsening HFrEF symptoms and has required three hospitalizations for decompensated HF. He currently endorses New York Heart Association (NYHA) functional class IIIb HF symptoms.
On physical examination, his heart rate (HR) is 63 bpm and regular, blood pressure is 98/65 mm Hg, body mass index is 23.0, jugular venous distension is present, point of maximal impulse is laterally displaced, S3 gallop is appreciated, lungs are clear to auscultation, and no peripheral edema is appreciated.
An electrocardiogram has findings of biventricular pacing with QRS duration 115 msec. A transthoracic echocardiogram has findings of left ventricular ejection fraction (LVEF) 18%, left ventricular (LV) internal diastolic diameter 6.2 cm, and moderate mitral regurgitation (MR). Laboratory study results include N-terminal pro–B-type natriuretic peptide level 3500 pg/mL, hemoglobin level 12 g/dL, and estimated glomerular filtration rate 48 mL/min/1.73 m2.
The correct answer is: C. Refer to advanced HF for consideration of advanced therapies.
The best next step in the management of this patient's symptoms would be referring to advanced HF for consideration of advanced therapies. He had several markers of advanced HF, including persistent NYHA class IIIb HF symptoms, recurrent hospitalizations, hypotension-limiting GDMT, elevated natriuretic peptide levels, and severely reduced LVEF; he should be referred for evaluation for advanced therapies including durable LV assist device and heart transplant.1-8
Increasing the dose of HF-specific beta-blocker therapy would be an incorrect choice because his HR was 63 bpm, he had recent symptomatic hypotension, and he was likely volume overloaded. Referring to electrophysiology for assessment of CRT-D optimization would be an incorrect choice because the QRS was narrow, indicating his CRT-D was likely optimized.9-11 Referring to the Structural Heart Team for consideration of transcatheter MV repair would be an incorrect choice because the guidelines for MV transcatheter edge-to-edge repair require patients to be stabilized on medical therapy and have LVEF 20-50% with persistent severe MR.12-14
This patient case quiz is part of the Beyond the Pill: Advancing Heart Failure Care With Monitoring and Device Therapy initiative. Educational Grant Support Provided By: CVRx, Edwards Lifesciences, Abbott.
References
- 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(17):e263-e421. doi:10.1016/j.jacc.2021.12.012
- Jorde UP, Shah AM, Sims DB, et al. Continuous-flow left ventricular assist device survival improves with multidisciplinary approach. Ann Thorac Surg. 2019;108(2):508-516. doi:10.1016/j.athoracsur.2019.01.063
- Estep JD, Starling RC, Horstmanshof DA, et al. Risk assessment and comparative effectiveness of left ventricular assist device and medical management in ambulatory heart failure patients: results from the ROADMAP Study. J Am Coll Cardiol. 2015;66(16):1747-1761. doi:10.1016/j.jacc.2015.07.075
- Cowger JA, Naka Y, Aaronson KD, et al. Quality of life and functional capacity outcomes in the MOMENTUM 3 trial at 6 months: a call for new metrics for left ventricular assist device patients. J Heart Lung Transplant. 2018;37(1):15-24. doi:10.1016/j.healun.2017.10.019
- Stehlik J, Estep JD, Selzman CH, et al. Patient-reported health-related quality of life is a predictor of outcomes in ambulatory heart failure patients treated with left ventricular assist device compared with medical management: results from the ROADMAP study (Risk Assessment and Comparative Effectiveness of Left Ventricular Assist Device and Medical Management). Circ Heart Fail. 2017;10(6):e003910. doi:10.1161/CIRCHEARTFAILURE.116.003910
- Allen LA, McIlvennan CK, Thompson JS, et al. Effectiveness of an intervention supporting shared decision making for destination therapy left ventricular assist device: the DECIDE-LVAD randomized clinical trial. JAMA Intern Med. 2018;178(4):520-529. doi:10.1001/jamainternmed.2017.8713
- Saeed D, Feldman D, Banayosy AE, et al. The 2023 International Society for Heart and Lung Transplantation guidelines for mechanical circulatory support: a 10- year update. J Heart Lung Transplant. 2023;42(7):e1-e222. doi:10.1016/j.healun.2022.12.004
- Antonopoulos M, Bonios MJ, Dimopoulos S, et al. Advanced heart failure: therapeutic options and challenges in the evolving field of left ventricular assist devices. J Cardiovasc Dev Dis. 2024;11(2):61. Published 2024 Feb 16. doi:10.3390/jcdd11020061
- Cleland JG, Daubert JC, Erdmann E, et al. The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med. 2005;352(15):1539-1549. doi:10.1056/NEJMoa050496
- St John Sutton MG, Plappert T, Abraham WT, et al. Effect of cardiac resynchronization therapy on left ventricular size and function in chronic heart failure. Circulation. 2003;107(15):1985-1990. doi:10.1161/01.CIR.0000065226.24159.E9
- Chung MK, Patton KK, Lau CP, et al. 2023 HRS/APHRS/LAHRS guideline on cardiac physiologic pacing for the avoidance and mitigation of heart failure. Heart Rhythm. 2023;20(9):e17-e91. doi:10.1016/j.hrthm.2023.03.1538
- Writing Committee Members, Otto CM, Nishimura RA, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2021;77(4):e25-e197. doi:10.1016/j.jacc.2020.11.018
- Stone GW, Lindenfeld J, Abraham WT, et al. Transcatheter mitral-valve repair in patients with heart failure. N Engl J Med. 2018;379(24):2307-2318. doi:10.1056/NEJMoa1806640
- Hahn RT, Chan V, Adams DH. Current indications for transcatheter edge-to-edge repair in a patient with primary mitral regurgitation. Circulation. 2022;146(17):1263-1265. doi:10.1161/CIRCULATIONAHA.122.061495
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