Challenges and Opportunities for Better Heart Failure Care

An 82-year-old female with heart failure (HF), hypertension, diabetes mellitus, atrial fibrillation, prior stroke, and osteoarthritis was hospitalized with HF exacerbation in the setting of presumed dietary indiscretion. Over the preceding week she had been traveling to visit family for the holidays. Her diet was atypical, she developed a cough, rhinorrhea, and was feeling slightly more dyspneic with increased edema in her ankles. She did not weigh herself until returning home and was 11 pounds higher than average. She self-managed this by doubling her prescribed dose of furosemide for 3 days, but her weight did not improve significantly. She reported feeling worsening weakness and her blood pressure at home was 104/55, which was low for her. She felt very unsteady when ambulating in her home and fell without reported loss of consciousness. She called her physician, went to the hospital, and was admitted for further care.

At admission her temperature was 99.1° F, blood pressure was 112/61 mmHg, heart rate 89 bpm, and oxygen saturation 95%. Her physical examination revealed mild bibasilar rales, an irregular rhythm, and 2+ bilateral edema to her knees. Her outpatient medications included furosemide 80 mg once daily, lisinopril 40 mg once daily, and diltiazem ER 360 mg once daily.

While hospitalized an echocardiogram was obtained and showed an unchanged left ventricular ejection fraction of 45-50%, grade 3 diastolic dysfunction with elevated filling pressures, mild mitral regurgitation, and tricuspid regurgitation with an estimated pulmonary artery systolic pressure of 42 mmHg. She was diuresed with IV furosemide and after 3 days her weight was significantly improved. She was able to ambulate without dyspnea on the ward, she was feeling more stable but still weak, and her blood pressure was improved at 122/76. Discharge to home was anticipated for the following day.

In addition to education and adjustment of her diuretics, which of the following should be done to optimize this patient's long-term HF care?

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