Patient background
A 68-year-old man with a history of hypertension and type 2 diabetes presents with acute decompensated heart failure, reporting progressive dyspnea, two-pillow orthopnea, and bilateral lower extremity edema. He has a 5-year history of chronic heart failure with reduced ejection fraction (HFrEF) but has only been on loop diuretics for the past year, with no other components of guideline-directed medical therapy (GDMT) prescribed. His family history is notable for premature cardiovascular deaths in first-degree relatives.
Assessment and diagnosis
On exam, the patient had diminished breath sounds, bilateral basal crackles, elevated jugular venous pressure, and pitting edema to the mid-shins. His oxygen saturation was 95% on room air. Echocardiogram revealed a reduced left ventricular ejection fraction (LVEF) of 25%, confirming HFrEF. Laboratory evaluation showed serum creatinine 1.4 mg/dL, eGFR 48 ml/min/1.73m², and potassium 4.2 mEq/L. Following treatment with intravenous loop diuretics, he achieved near-euvolemia and maintained a stable systolic BP of 115 mmHg without requiring inotropic support. Final diagnosis: acute on chronic HFrEF. Plans were made to initiate GDMT during hospitalization and to schedule outpatient follow-up for reassessment and titration.
- How do you initiate and optimize guideline-directed medical therapy in acute decompensated heart failure?
- How do you integrate newer agents like SGLT2 inhibitors into established GDMT sequencing in your practice?
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