Case study I CHF

A 58-year-old man has been diagnosed with systolic heart failure (HF) with New York Heart Association (NYHA) class-II symptoms and ejection fraction 25%. The patient had a history of hospitalizations for heart failure. The chief complaints of the patient were dyspnea on exertion (DOE), poor sleep and appetite. (*This case is hypothetical and designed for educative purpose only.) Demographics: Age: 58 years Gender: Male Weight: 80 kg BMI: 4 kg/m2 Height : 177 cms Medical History: Known case of hypertension and type-2 diabetes Had undergone percutaneous transluminal coronary angioplasty (PTCA) to left anterior descending coronary artery (LAD) Ischemic dilated cardiomyopathy Dyspnea on exertion (DOE), tiredness The patient was earlier treated with: Enalapril Carvedilol Spironolactone Metformin 1000 mg Atorvastatin 40 mg Digoxin 0.25 mg daily Clinical Investigations: Serum N-Terminal Pro–B-Type Natriuretic Peptide (NT-proBNP) = 1200 pg/ml Body mass index = 25.4 kg/m2 Estimated GFR = 45 mL/min/1.73m2 Serum creatinine = 1.50 mg/dl Serum potassium = 7 mEq/L BP = 136/90 mmHg Heart Rate = 75 beats/min HbA1c = 7.9 % Treatment Advised In Addition To Existing Therapy: Discontinue Enalapril After washout period of 36 hrs; start Sacubitril/ valsartan at dose of 100mg twice daily Add Linagliptin 5 mg once daily along with Metformin Add Furosemide (40mg) – once daily The patient was specifically switched from the angiotensin converting enzyme (ACE) inhibitor he had been receiving earlier to Sacubitril/Valsartan regimen. The wash out period between this switch was 36 hours. Follow-up visit after 4 weeks: Treatment has been continued and a dose of Sacubitril/Valsartan has been changed to 200 mg twice daily. Therapeutic goals: To reduce the total HF hospitalizations. To check NT-proBNP level Maintain normal Blood pressure and blood sugar. At the end of 12 weeks: Serum N-Terminal Pro–B-Type Natriuretic Peptide (NT-proBNP) = 800 pg/ml Body mass index = 4 kg/m2 Estimated GFR = 49 mL/min/1.73m2 Serum creatinine = 1.30 mg/dl Serum potassium = 6 mEq/L BP = 132/88 mmHg Heart Rate = 70 beats/min HbA1c = 7.4 % Discussion: No hospitalization after starting of Sacubitril/Valsartan during 12 weeks follow up. PARADIGM HF trial shows the advantage of Sacubitril/Valsartan in patients with heart failure over ACE inhibitors. Similar advantages were observed in this study which also showed Sacubitril/ valsartan is superior to enalapril in reducing the risks of death and of hospitalization. The Sacubitril/ Valsartan therapy along with background regimen improved the overall clinical profile of the patient. Beta blocker should be continued in these patients as they are thought to offer long term cardio protection. Addition of Linagliptin reported better glycemic control which was demonstrated by a decrease in HbA1c levels. No chest pain, pedal edema was observed. No hyperkalemia noted on a routine Follow-up Instructions: The patient was advised to do regular exercise and to keep regular appointments. He was also instructed to take medications on time, reduce salt intake and monitor his fluid intake up to25 liters. Key Learnings and Recommendations: It is observed that Sacubitril/Valsartan can be used as a replacement to ACEi or ARB in HFrEF patients. Sacubitril/Valsartan can be used in HFrEF patients who are on a β-blocker and/ MRA. The study also revealed that Sacubitril/Valsartan is well tolerated and can be considered as a treatment option to use in HF patients. In summary, Sacubitril/Valsartan significantly improved clinical outcomes during heart failure in the setting of hypertension and coronary artery disease. From these observations, what are the practical considerations for use of Sacubitril/Valsartan in HFrEF patients? Safety and efficacy of Empagliflozin in a geriatric patient were discussed in the previous article. Click here to read more. CardiologyCritical CareTrauma & Emergency Medicine + 2 more Do you recommend Sacubitril/Valsartan in place of ACEi for HFrEF patients? Yes Share your views 21 doctors have said yes