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1yr
Addressing heart failure risk in a 54-Year-old male with type 2 diabetes

Initial Complaints: A 54-year-old male, presented with fatigue, mild shortness of breath, and occasional ankle swelling.

Brief History: His medical history includes well-controlled type 2 diabetes mellitus (T2D), hypertension, and obesity (BMI 32 kg/m²). He has no prior history of coronary artery disease or myocardial infarction, but both parents had heart disease.

Clinical Examination: Physical examination revealed bilateral ankle edema, jugular venous distension, and slightly elevated blood pressure (140/90 mmHg).

His weight was 110 kg, and heart sounds were regular with no murmurs. Symptoms included shortness of breath on exertion, likely exacerbated by obesity.

Diagnostic Workup: Echocardiography showed preserved left ventricular ejection fraction (LVEF) of 68%, indicating normal pump function. However, global longitudinal strain (GLS) was -16%, suggesting subclinical left ventricular dysfunction likely due to long-standing hypertension, diabetes, and obesity.

Laboratory Results: Routine blood tests indicated HbA1c at 6.8%. Kidney function was normal (eGFR 72 mL/min/1.73 m²). N-terminal pro-brain natriuretic peptide (NT-proBNP) levels were slightly elevated, indicating cardiac stress. The lipid panel revealed elevated triglycerides and borderline high LDL cholesterol.

  1. What is the patient’s diagnosis based on the presented symptoms and diagnostic findings?
  2. What percentage of patients with heart failure also have obesity-related complications?
  3. What are the next steps in management for this patient?
  • 1yr
    The patient appears to have CHF with preserved EF. I would treat him with a loop diuretic and aldactone. Since he has high BP would add ACE /ARB or Entresto even though he has preserved EF. Since he is diabetic, obese and has HTN I would use a SGLT2 and GLP1 for both diabetic control and weight loss in this patient population. I would assess for OSAS in this patient population too.
  • 1yr
    The patient has heart failure with preserved ejection fraction. Overweight or obesity, according to a brief literature search, occurs in over 80% of patients with HFpEF, which is especially interesting given the recent data around the use of semaglutide and tirzepatide for these patients. Initially, we would want to get patients on GDMT (SGLT2, MRA, ARNI), decongested, and then discuss additional therapies for management of both his glucose and weight, including the GLP-1's as above.
  • 1yr
    The patient has signs and symptoms c.w HFPEF. He clinically has heart failure. He also meets criteria for metabolic syndrome with obesity, HTN and HLD. I's not certain what the exact percentage of patients with diastolic HF and obesity. He should first be treated for volume overload and then initiated on GDMT for HFPEF including SGLT2 inhibition, MRA and ACEI/ARB Tx. In setting of obesity and borderline DM would consider addition of GLP1 agonist Rx.
  • 1yr
    Pt has diastolic CHF.
    Hi percentage of these patients have obesity and elevated BP
    Evidence based medicine requires starting Jardiance/Farxiga but there is enough evidence now that Ozempic et all have similar cardiac benefits and will also treat the obesity which is a major underlying cause. Would also start spironolactone to facilitate diuresis, for BP, and because of recent evidence of benefit of this class in diastolic CHF.
    Given DM and elevated BP would also start ACE/ARB
    Would screen for sleep apnea.
  • 1yr
    1. He meets the criteria for HFpEF since evidence for congestion/fluid retention by symptoms and signs and objective evidence by elevated BMP. Confidence of HFpEF would be greater if stage 2 or greater diastolic dysfunction and elevated E/e' were present on echo and NT-proBNP was more than slightly elevated.
    2. I don't know what precentage of heart failure patients have obesity or obesity related complications. I believe the question should be what percentage of obese patients develop CHF.
    3. Life style changes should be attempted first, with weight loss and whole food plant based diet. Weight loss and diet alone might correct his BP and cure diabetes, as well as remove signs of fluid retention. If unsuccessful, then SGLT2 inhibitor or semaglutide/mounjaro and ACEI/ inibitor/ARB/ARNI would be the next treatments. If unable to afford SGLT2 inhibitor or semaglutide/mounjaro, then metformin would be alternative.
  • 1yr
    He has HFpEF based on clinical exam, biomarkers and and Echo findings
    Would recommend SoC with SGLT-2 inhibitors such as Jardiance and Farxiga
    Weight loss with diet and exercise, also consider GLP1 for weight loss
  • 1yr
    1. His diagnosis is HFpEF, with all of the classic findings and risk factors. It is early in his course (only borderline BNP), so interventions at this point will hold long term benefits
    2. I would guess in the range of 50% of HFpEF patients have obesity. I suspect it is much lower percentage for HFrEF
    3. Would strongly consider and SGLT inhibitor (Jardiance, Farxiga) now which may spare him the need for other diuretics. Weight loss and exercise will help significantly and may require GLP 1 agonists (Oxempic, etc) if lifestyle changes are insufficient.
  • 1yr
    1) he meets the diagnosis for HefPef
    2)not sure but a better question is what percentage of obese patients develope CHF
    3) lifestyle modification , would also titrate up his anti hypertensive regimen ( ace arb or ARNI, diuretic and would consider adding stlg2
  • 1yr
    All points to HFpef. GDMT including a GLP1. Perhaps Finerenone vs Aldactone.
  • 1yr
    Dx is HFPEF - likely early stage. Heart failure and its complications very frequently are associated with obesity. Given his makeup and the HFPEF he would likely benefit from spironolactone, GLP1, and SGLT2I. This is of course in addition to lifestyle optimization such as diet/exercise/weight loss.
  • 1yr
    Pt has diabetes, mixed hyperlipidemia, hypertension, obesity, and diastoic CHF. Likely, metabolic syndrome; hi risk sleep apnea.
    A significant subset of diastolic CHF patients have obesity.
    For treatment he needs a diuretic, probably complemented by spironolactone. The diabetes calls for an ACE inhibitor and a statin.
    Would use Ozempic for the diabetes given the obesity with Jardiance or Farxiga a second choice given the CHF.
  • 1yr
    Preserved ejection fraction Heart failure is the likely diagnosis. He will need aggressive medical therapy in reference to GDMT. I am uncertain what percentage of CHF patients have obesity. Certainly there should be attention to lifestyle adjustment as well. Patient will need to meet with the dietitian. Patient would benefit from an increase in activity. Patient will need regular follow up with a cardiologist to monitor his compliance with his medication and monitor his weight and attention to his diet.
  • 1yr
    His symptoms and bio-markers are consistent with HFpEF. he should be on a SGLT-2 inhibitor such as Farxiga along with MRA and diuretics.
    Obesiy is associated with HFpEF and treatment of obesity with medications such as GLP1 should be strongly considered.
    Lifestyle modifications such as weight reduction, control of BP and diabetes is a top priority
  • 1yr
    i think its pretty clear that he has chf with preserved LV function. Evidence based medicine clearly states he should be on an sglt2 inhibitor as well as a MRA agent
    for bp control entresto may be useful but studies did not show definte statistical advantage to suggest agent
    since hear failure with preserved lv dunction is strongly associated with obesity and hypertension- both need to be address
    recent studies clearly show advantages in starting an glp1 agent for his condition
  • 1yr
    1. He meets the criteria for HFpEF since evidence for congestion/fluid retention by symptoms and signs and objective evidence by elevated BMP. Confidence of HFpEF would be greater if stage 2 or greater diastolic dysfunction and elevated E/e' were present on echo and NT-proBNP was more than slightly elevated.
    2. I don't know what precentage of heart failure patients have obesity or obesity related complications. I believe the question should be what percentage of obese patients develop CHF.
    3. Life style changes should be attempted first, with weight loss and whole food plant based diet. Weight loss and diet alone might correct his BP and cure diabetes, as well as remove signs of fluid retention. If unsuccessful, then SGLT2 inhibitor or semaglutide/mounjaro and ACE inibitor/ARB/ARNI would be the next treatments. If unable to afford SGLT2 inhibitor or semaglutide/mounjaro, then metformin would be alternative.
  • 1yr
    1. He meets the criteria for HFpEF since evidence for congestion/fluid retention by symptoms and signs and objective evidence by elevated BMP. Confidence of HFpEF would be greater if stage 2 or greater diastolic dysfunction and elevated E/e' were present on echo and NT-proBNP was more than slightly elevated.
    2. I don't know what precentage of heart failure patients have obesity or obesity related complications. I believe the question should be what percentage of obese patients develop CHF.
    3. Life style changes should be attempted first, with weight loss and whole food plant based diet. Weight loss and diet alone might correct his BP and cure diabetes, as well as remove signs of fluid retention. If unsuccessful, then SGLT2 inhibitor or semaglutide/mounjaro and ACE inibitor/ARB/ARNI would be the next treatments. If unable to afford SGLT2 inhibitor or semaglutide/mounjaro, then metformin would be alternative.

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