Hi, my name is Michelle and we've learned a lot about heart failure. Now let's talk about a case study to review the information. Let's talk a little bit about Ann Smith. Ann Smith is a 65-year-old female with a history of hypertension, hyperlipidemia, and diabetes. She comes into the emergency room with two weeks history of shortness of breath, mild exertion, lower extremity edema, and arthropnea. On physical exam, she has positive JVP and ankle edema. Her renal function and potassium are stable. She's had some labs done and her BMP is elevated to 1500, and her echocardiogram shows that her LVEF, or ejection fraction, is 35%. Note that she's also class 3 as regarding her NYHA scale. So let's talk about how we manage this patient. So the first thing we'll need to do is figure out why she has heart failure. As mentioned in the previous modules, talking a little bit about the pathophysiology of heart failure, there's many different reasons. In this individual, of course, we'd most likely start with a ischemic evaluation and make sure that she doesn't have coronary artery disease. Once her reason for heart failure is evaluated, we will talk about guideline-directed medical therapy. So our goal is to put her on the four pillars, which we talked about in our previous module. The goal is to get her started on a low-dose ARNI, make sure that we're watching her potassium and her electrolytes, but also watching her blood pressure. We'll also start with a low-dose beta blocker. In this case, I've chose Corvetolol 6.25 twice a day. She had good blood pressure when she was evaluated. We'll get her started on some Spiral Lactone 12.5, low dose, but be talking to her about making sure that we're watching her potassium levels and looking at her renal function. This will also need to be done as an outpatient. After getting prior approval by her insurance, we'll get her started on an SGL2 inhibitor. With all these medications, education is very important, as well as the use and the reasons for titration of medication. We'll follow up with her in seven to 10 days with labs, as well as a physical clinic appointment to make sure she's doing well with these medications, looking at her renal function and her potassium by her labs. The overall goal is to titrate these medicines over the next three months and get an echocardiogram in three months. What if her ejection fraction or LVEF is still less than 35%? At that time, she should be considered for an ICD. Unfortunately, with everything that we've done, Mrs. Smith comes back into the hospital. What do we do now? If guideline-directed medical therapy is not working and the patient continues to decline, have symptoms of heart failure, low cardiac output, right heart caths, and other monitoring can be done. Unfortunately, if the patient still continues to decline, they should be considered for advanced therapies. This patient, which is 65 years old, considering that she has no exclusion to being considered for an LVAD or a heart transplant, this should be considered and she should be referred to programs that have advanced therapy options. In conclusion, the goal is to get Ann Smith on goal-directed medical therapy. After that is completed, she should be considered for an ICD if her ejection fraction is less than 50. She should also be considered for remote monitoring. If all these strategies do not work, she should be considered for advanced therapies with that of an LVAD or heart transplant. Once again, I thank you for your time.

heart failure

case study

Ann Smith

hypertension

hyperlipidemia