Identifying Signs of Advanced Heart Failure

Nov 25, 2025   |  Supriya Shore, MD
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A 50-year-old man with a history of nonischemic, dilated cardiomyopathy with severely reduced left ventricular ejection fraction (LVEF) at 15% presents to the clinic. He has had three heart failure (HF) hospitalizations in the past 6 months and is currently taking lisinopril 5 mg daily, metoprolol succinate 12.5 mg daily, spironolactone 12.5 mg daily, empagliflozin 10 mg daily, and torsemide 100 mg twice daily. Attempts to uptitrate his medications have been associated with symptomatic hypotension. He had a cardiac resynchronization therapy with defibrillator implanted last year. He is considering applying for disability because he has baseline New York Heart Association (NYHA) class IIIb-IV HF symptoms and can no longer work at his job in a factory.

His vital signs include heart rate (HR) 92 bpm and blood pressure (BP) 90/66 mm Hg. His body mass index is 25.0 and weight is 80 kg. Physical examination reveals a grade 2/6 systolic murmur at the cardiac apex, which is laterally displaced. His lungs are clear to auscultation and there is no lower extremity edema.

A repeat transthoracic echocardiogram (TTE) reveals LVEF 15%, with left ventricular (LV) end-diastolic dimension 65 mm, severely dilated left atrium, and moderate mitral regurgitation. His laboratory study results at today's clinic visit include hemoglobin level 10.2 g/dL, white blood cell count 5 x 103/mcL, lymphocyte concentration 24%, sodium level 132 mmol/L, potassium level 4.8 mmol/L, creatinine level 1.6 mg/dL, estimated glomerular filtration rate 42 mL/min/1.73 m2, B-type natriuretic peptide (NP) level 700 pg/mL, uric acid level 7 mg/dL, and total cholesterol level 200 mg/dL.

Which one of the following is the best next step in managing his symptoms?

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