How would you classify her heart failure? What changes (modifications, additions, deletions) to her medications do you recommend that will: Improve her symptoms? Impact long term outcomes? What monitoring parameters do you recommend? What non-pharmacologic recommendations do you have?

A 50yo African American woman presents to clinic feeling tired for the last 3 months.  She also has trouble breathing when walking 2-3 blocks.  She sleeps on 2 pillows at night to help with her breathing.  PMH:  HTN, arthritis.  Physical exam: edema present in both feet.  Medications:  HCTZ 12.5mg daily, verapamil SA 120 mg daily, ibuprofen 200 mg BID for arthritis in knee.  Vitals:  height 5’2″, 63kg, BP 134/84, HR 78, EF 30% per echocardiogram.  Her labs are normal including a creatinine of 1.1.  She denies chest pain or palpitations.  Her EKG reveals normal sinus rhythm with no evidence of ischemia or recent acute coronary syndrome.

1. How would you classify her heart failure?
2. What changes (modifications, additions, deletions) to her medications do you recommend that will:
   • Improve her symptoms?
   • Impact long term outcomes?
3. What monitoring parameters do you recommend?
4. What non-pharmacologic recommendations do you have?

5. 1. Classification of Heart Failure

   Based on the American College of Cardiology (ACC)/American Heart Association (AHA) classification:

   • Stage C : Structural heart disease (EF 30%) with current or prior symptoms of heart failure.
   • Type : Heart Failure with Reduced Ejection Fraction (HFrEF) – EF <40%.

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   ✅ 2. Medication Changes to Improve Symptoms and Long-Term Outcomes

   🔺Current Medications:

   • Hydrochlorothiazide (HCTZ) 12.5 mg daily – Diuretic
   • Verapamil SA 120 mg daily – Non-dihydropyridine calcium channel blocker (CCB)
   • Ibuprofen 200 mg BID – NSAID

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   🚫 Medication Modifications Needed:

   ❌ Discontinue Verapamil SA

   • Rationale: Verapamil and diltiazem are non-dihydropyridine CCBs , which can worsen heart failure due to negative inotropic effects. These are generally contraindicated in HFrEF , especially symptomatic patients.

   ❌ Discontinue Ibuprofen

   • Rationale: NSAIDs like ibuprofen can cause fluid retention , increase blood pressure, and reduce the effectiveness of diuretics and RAAS inhibitors. They should be avoided in heart failure.

   ✔️ Add Guideline-Directed Medical Therapy (GDMT) for HFrEF

   These medications have been shown to improve both symptoms and mortality :

   1. Angiotensin-Converting Enzyme Inhibitor (ACE-I) or Angiotensin Receptor Blocker (ARB)
      • Start Lisinopril 5 mg daily (if no contraindications like hypotension, hyperkalemia, renal insufficiency).
      • If ACE-I not tolerated, use valsartan (ARB).
   2. Beta-blocker – Start Carvedilol or Metoprolol succinate
      • Start low dose (e.g., carvedilol 3.125 mg BID or metoprolol succinate 25 mg daily) and titrate slowly.
      • Beta-blockers reduce mortality and hospitalization in HFrEF.
   3. Mineralocorticoid Receptor Antagonist (MRA) – Spironolactone 25 mg daily
      • Consider after starting ACE-I/ARB and beta-blocker if creatinine ≤2.5 and K ≤5.0.
      • Reduces mortality and hospitalizations in moderate-severe HFrEF.
   4. SGLT2 Inhibitor – Dapagliflozin or Empagliflozin
      • Even in non-diabetic patients, these drugs have shown benefit in HFrEF.
      • Reduce hospitalization and improve outcomes.
   5. Loop Diuretic – Furosemide 20–40 mg daily
      • The patient has signs of congestion (edema, orthopnea). HCTZ may not be sufficient.
      • Replace HCTZ with a loop diuretic for better volume control.

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   ✅ Summary of Medication Changes:

   Medication	Change	Rationale
   Verapamil SA	Discontinue	Negative inotropy; contraindicated in HFrEF
   Ibuprofen	Discontinue	Worsens HF, reduces efficacy of HF meds
   HCTZ	Replace with furosemide	Loop diuretic more effective in HF
   Add Lisinopril or Valsartan	Start low, titrate up	Improves survival and symptoms
   Add Carvedilol or Metoprolol succinate	Start low, titrate	Reduces mortality
   Add Spironolactone	After RAASi and BB initiated	Further mortality benefit
   Add Dapagliflozin or Empagliflozin	Regardless of diabetes	Proven benefit in HFrEF

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   ✅ 3. Monitoring Parameters

   • Blood Pressure & Weight – Daily monitoring at home
   • Weight gain >2–3 lbs in 2 days – sign of fluid retention
   • Serum Electrolytes, Creatinine, and Potassium – Monitor every 1–2 weeks initially after initiating or titrating GDMT
   • Ejection Fraction – Repeat echo in 3–6 months to assess response
   • Symptoms – Dyspnea, fatigue, orthopnea, edema
   • Adherence and Side Effects – Regular follow-up with provider

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   ✅ 4. Non-Pharmacologic Recommendations

   • Sodium Restriction – Limit to <2 g/day
   • Fluid Restriction – Consider <2 L/day if moderate-severe HF or hyponatremia
   • Daily Weighing – Track weight changes
   • Smoking & Alcohol Cessation – If applicable
   • Cardiac Rehabilitation – Structured exercise improves functional capacity and quality of life
   • Vaccinations – Annual influenza vaccine, pneumococcal vaccine, and updated COVID vaccines
   • Weight Management – Encourage healthy BMI and waist circumference
   • Sleep Apnea Screening – Especially if snoring or daytime sleepiness
   • Education – Recognizing worsening symptoms and when to seek care

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   🔁 Summary

   This patient has HFrEF (Stage C) . Her current regimen includes potentially harmful medications (verapamil, ibuprofen) and lacks evidence-based therapies that improve symptoms and mortality.

   Key steps:

   • Discontinue verapamil and ibuprofen
   • Initiate GDMT: RAAS inhibitor, beta-blocker, MRA, SGLT2 inhibitor
   • Use loop diuretic for symptom control
   • Implement lifestyle modifications and close monit