Learner Version
MODULE #25
Created by Dr. Manish Sharma
01/31/2014
OBJECTIVES:
On Facilitator Version
REFERENCES:
On Facilitator Version
CASE
*M.J. is a 55 year-old African American male with past medical history of Hypertension and Diabetes
Mellitus type 2 who presents to the ED with one month history of progressively worsening shortness of
breath and lower extremity swelling. Previously, he had no limitations in activity. Now, he gets short of
breath with walking to the bathroom or climbing one flight of stairs. He also notes worsening breathing
when lying in bed and has been waking up at night due to shortness of breath. He does not report any
fever, chills, palpitations, chest pain, cough, nausea or vomiting. He smokes one pack of cigarettes per
day. He has not been regularly taking his Hydrochlorothiazide and Metformin. Three months ago, his
hemoglobin A1c was 11%. His father suffered a heart attack at the age of 50.
On physical examination, he appears comfortable sitting up right at rest. His blood pressure is 155/95
mm Hg. His heart rate is 85 bpm, regular. His respiratory rate is 18 per minute. He is afebrile. His BMI
is 32. His oxygen saturation is 85% on room-air and this improves to 94% on 2 LPM via NC. Neck exam
demonstrates elevated JVP. Auscultation of the chest demonstrates rales posteriorly in the lower onethird of the lung fields. Cardiac exam demonstrates normal S1 and S2. There is S3 present. There is also
a II/VI systolic ejection murmur at the lower left sternal border radiating to the axilla. Abdomen is soft
and no tenderness is palpated. There is 2+ pitting edema of the legs extending to the knees.
What is the most likely diagnosis?
Which tests would you order at this time?
What is the role of BNP or NT-proBNP in the evaluation and treatment of heart failure?
What is his NYHA functional class and what is his ACCF/AHA stage?
*CBC is normal. Electrolytes including Ca++ and Mg+ are normal. Glucose is 230 mg/dL.
TSH is in the normal range. Troponin I is in the normal range. LFTs are normal.
Renal function is normal. Hemoglobin A1c is 12%.
NT-proBNP is 12,000 pg/mL.
Total cholesterol is 230 mg/dL, LDL 150 mg/dL, Triglycerides 315 mg/dL and HDL 25 mg/dL.
UA is normal except for glycosuria.
ECG shows q waves in the inferior leads.
CXR shows diffuse increased interstial opacities, including kerley B lines; prominent and indistinct
pulmonary vasculature and tiny pleural effusions.
Echocardiogram shows normal LV size. There is inferior and lateral wall hypokinesis. LVEF is 35%.
What are the immediate goals of treatment?
*You have admitted M.J. to the cardiac monitoring unit of your hospital. He is treated with IV Lasix. He
is started on Lisinopril. His dyspnea and lower extremity edema improves.
Discuss the role of diuretics in the treatment of ADHF
Discuss the role of angiotensin converting enzyme inhibitors (ACE-Is)/angiotensin receptor blockers
(ARBs) in the treatment of HF
What are some of the common causes of heart failure?
*Now his symptoms have resolved. He is ambulating in the hallways without dyspnea or any limitations.
He is started on Metoprolol Succinate XR.
Discuss the role of B-blockers in the treatment of HF
*M.J. undergoes a cardiac catheterization which shows multi-vessel CAD and he gets a CABGx3V prior to
discharge. He is discharged from the hospital on Aspirin, Lasix, Lipitor, Lisinopril, Metoprolol Succinate
XR, Glargine and Aspartate insulin. He is given instructions on low-fat, low-cholesterol and no added salt
diet. He is given instructions on monitoring for symptoms of heart failure. He is taught to monitor his
weight at home. He is advised to stop smoking. He follows up one week after hospital discharge in the
CHF clinic. He is doing well and has no symptoms. His heart failure medications are titrated to target
doses.
*Five years later, M.J. presents to the ED with two days of worsening dyspnea. He is admitted to the
hospital with the diagnosis of NSTEMI and ADHF. He undergoes another cardiac catheterization and is
now found to have non-revascularizable vessels. His ECG now shows NSR, a new LBBB with a QRS
interval of 150 mseconds. His Echocardiogram now shows anteroapical and inferolateral wall
hypokinesis with LVEF of 25%.
Discuss the role of Aldosterone receptor antagonists in the treatment of HFrEF
*M.J. is treated for NSTEMI and ADHF. He is discharged from the hospital on Epeleronone, Lasix,
Aspirin, Plavix, Lipitor, Lisinopril, Metoprolol Succinate XR, Glargine and Aspartate insulin. He remains
symptomatic with minimal exertion despite maximal medical therapy.
What is M.J’s Seattle Heart Failure Survival score?
Are there any other medications for HFrEF that M.J. would benefit from?
Is there any device that M.J. could benefit from?
Discuss treatment options for patients with end-stage heart failure?
MKSAP 16 QUESTIONS:
#15—Treating HFpEF
#17—Treating HFrEF
#24—Treating HFrEF
#36—Treating HFrEf
#54—Treating HFrEf
#58—Treating ADHF
#75—Treating HFrEf
#80—ADHF
#97—Treat HFrEF
#102—Treating HFrEF
#120—Treat HTN in a patient with HFrEF
Appendix 1:
Below is the guideline directed medical therapy (GDMT) and the magnitude of benefit demonstrated in
RCTs:
Table 3:
Medical Therapy for Stage C HFrEF: Magnitude of Benefit Demonstrated in RCTs
GDMT
RR Reduction in
Mortality (%)
NNT for Mortality
RR Reduction
Reduction
in HF Hospitalizations
(Standardized to 36 mo)
(%)
ACE inhibitor or ARB
17
26
31
Beta blocker
34
9
41
30
6
35
43
7
33
Aldosterone
antagonist
Hydralazine/nitrate
ACE indicates angiotensin-converting enzyme; ARB, angiotensin-receptor blocker; GDMT,
guideline-directed medical therapy; HF, heart failure; HFrEF, heart failure with reduced ejection
fraction; NNT, number needed to treat; RCTs, randomized controlled trials; and RR, relative risk.
Adapted with permission from Fonarow et al.201
Post Module Evaluation
Please send completed evaluation to Wendy Gerstein, VAMC (111) or Patrick Rendon, UNMH.
1) Topic of module:__________________________
2) On a scale of 1-5, how effective was this module for learning this topic? _________
(1= not effective at all, 5 = extremely effective)
3) Were there any obvious errors, confusing data, or omissions? Please list/comment below:
______________________________________________________________________________
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4) Was the attending involved in the teaching of this module? Yes/no (please circle).
5) Please provide any further comments/feedback about this module, or the inpatient curriculum
in general:
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