Optimizing the Symptomatic: Non-Medical Options for the Heart Failure Patient

A 45-year-old Caucasian male is seen in clinic complaining of shortness of breath. He has a history of heart failure with reduced ejection fraction (HFrEF) secondary to coronary artery disease and is status post 3-vessel coronary artery bypass graft (CABG) surgery along with percutaneous coronary intervention to the right posterior descending artery. A recent echocardiogram demonstrated improvement in his ejection fraction from 15% to 25% after cardiac resynchronization therapy and defibrillator (CRT-D) implantation. The repeat echocardiogram continued to show mild LV dilatation with antero-apical akinesis. Nuclear stress test did not demonstrate any area of reversible ischemia. A sleep study was performed and the patient was started on continuous positive airway pressure. He is on appropriate guideline-directed medical therapy that includes carvedilol 37.5mg PO BID, losartan 100mg PO daily, spironolactone 25mg PO daily, and furosemide 40mg twice a day. A physical exam did not demonstrate evidence of volume overload. He was then sent for a functional VO2 study that revealed a good exercise capacity with a peak VO2 of 21 mL/kg/min. Despite this, he continued to have dyspnea with New York Heart Association (NYHA) functional class III symptoms.

Which of the following is the next step you should consider?

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