A 77-year-old man with a long-standing history of hypertension comes to the office due to exertional shortness of breath and fatigue. He went to the emergency department 4 weeks ago for shortness of breath and was treated with intravenous diuretics. Echocardiogram at that time showed left atrial enlargement, left ventricular hypertrophy, and a left ventricular ejection fraction of 65%. Medications include daily furosemide 40 mg, amlodipine 10 mg, spironolactone 12.5 mg, and low-dose aspirin.
Blood pressure is 128/76 mm Hg and pulse is 74/min. Jugular venous pressure is estimated at 9 cm H₂O. Cardiac examination is notable for an S4 gallop and nondisplaced apical impulse. Lung auscultation reveals bibasilar crackles. The abdomen is nondistended and nontender to palpation. There is bilateral pitting ankle edema.
ECG shows normal sinus rhythm and voltage criteria for left ventricular hypertrophy. Serum potassium is 4.1 mEq/L and serum creatinine is 0.9 mg/dL.
Which of the following is the best treatment option for this patient?

Question

Quizplus · Accepted Answer

11ec193a_976f_8bc1_853d_5d90ba2337fc_MD0002_00 This patient's presentation is consistent with heart failure with preserved ejection fraction (HFpEF), resulting from impaired left ventricular diastolic relaxation (ie, diastolic dysfunction). Diastolic heart failure accounts for approximately half of decompensated heart failure hospitalizations. Patients characteristically have normal left ventricular ejection fraction (>50%) and objective evidence of diastolic dysfunction (elevated left ventricular filling pressures) by noninvasive or invasive measurement. In comparison with heart failure with reduced ejection fraction (HFrEF), HFpEF has overall demonstrated less response to neurohormonal antagonists (eg, angiotensin system blockers, beta blockers); however, aldosterone antagonists (eg, spironolactone) have been shown to reduce hospitalizations and possibly improve survival. Optimal management of HFpEF involves the following: Afterload reduction (ie, blood pressure <130/80 mm Hg). Aldosterone antagonists are first-line therapy.Treatment of volume overload with diureticsTreatment of exacerbating conditions (eg, rate control of atrial fibrillation, coronary revascularization) Afterload reduction (ie, blood pressure <130/80 mm Hg). Aldosterone antagonists are first-line therapy. Treatment of volume overload with diuretics Treatment of exacerbating conditions (eg, rate control of atrial fibrillation, coronary revascularization) This patient with dyspnea, bibasilar crackles, and peripheral edema would benefit from an increased dose of furosemide. (Choice A) Combination therapy with hydralazine and isosorbide dinitrate causes balanced vasodilation and can be useful in patients with HFrEF who cannot tolerate angiotensin system blockers. However, these drugs are not indicated in this normotensive patient with HFpEF. (Choice B) Losartan improves symptoms and mortality in patients with HFrEF but is not indicated in this normotensive patient with HFpEF. (Choice C) The thiazide diuretic metolazone is often used to potentiate the effect of loop diuretics in patients with severe heart failure. This patient is on a relatively low dose of furosemide; increasing (eg, doubling) the dose is likely to result in adequate diuresis, and metolazone is not needed at this time. (Choice D) Patients with HFpEF are poorly tolerant of elevated ventricular rates that can occur with comorbid atrial fibrillation, and metoprolol is useful in such patients. However, in the absence of atrial fibrillation or another clear indication (eg, stable angina), beta blockers are not recommended for HFpEF. Educational objective: Heart failure with preserved ejection fraction (HFpEF) results from impaired left ventricular diastolic relaxation (ie, diastolic dysfunction). Optimal therapy for HFpEF involves blood pressure control, treatment of volume overload with diuretics, and management of exacerbating conditions (eg, atrial fibrillation, coronary artery disease). __________ References: Pharmacologic management of heart failure with preserved ejection fraction. (http://www.ncbi.nlm.nih.gov/pubmed/21098754)

A 77-Year-Old Man with a Long-Standing History of Hypertension Comes