72-year-old woman with dyspnea and edema
A 72-year-old woman with a history of hypertension, obesity, and type 2 diabetes mellitus presents to your clinic with 3 months of progressive exertional dyspnea and bilateral lower extremity swelling. Her medications include lisinopril, metformin, and furosemide. Her blood pressure is 138/84 mmHg, heart rate is 78/min, and BMI is 34 kg/m². Examination reveals bibasilar crackles and 1+ pitting edema to the mid-shins. Jugular venous pressure is 9 cm. Laboratory studies show a potassium of 5.1 mEq/L and a creatinine of 1.3 mg/dL (eGFR 42 mL/min/1.73 m²). An echocardiogram demonstrates a left ventricular ejection fraction of 55% with grade 2 diastolic dysfunction. In addition to optimizing her diuretic regimen, which of the following is the most appropriate medication to add to reduce the risk of future heart failure hospitalizations?
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B
Explanation
Clinical Pearl:
In patients with heart failure with preserved ejection fraction (HFpEF), SGLT2 inhibitors are a foundational therapy recommended to reduce the risk of heart failure hospitalizations, regardless of diabetes status.
Explanation:
This patient presents with classic signs and symptoms of heart failure, and her echocardiogram showing a normal ejection fraction with diastolic dysfunction confirms the diagnosis of heart failure with preserved ejection fraction (HFpEF). According to current cardiology society guidelines, sodium-glucose cotransporter 2 (SGLT2) inhibitors are recommended for all patients with HFpEF to reduce the risk of heart failure hospitalizations and cardiovascular death. Dapagliflozin is an SGLT2 inhibitor shown to be effective for this indication, and the patient's eGFR is well above the threshold for initiation. Spironolactone, a mineralocorticoid receptor antagonist, is a plausible option but is relatively contraindicated in this patient due to her baseline potassium of 5.1 mEq/L. Digoxin has no proven mortality or hospitalization benefit in HFpEF and is not indicated. The combination of isosorbide dinitrate and hydralazine is a therapy for heart failure with reduced ejection fraction (HFrEF), particularly in African American patients, and has no established role in HFpEF. While sacubitril-valsartan has a class 2b recommendation in select patients with HFpEF, SGLT2 inhibitors have a stronger recommendation (class 2a) and are considered a more foundational therapy.
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