Guidelines: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure – Question #22 with Dr. Prateeti Khazanie

By CardioNerds - Last Updated: December 11, 2023

In this CardioNerds podcast episode: The CardioNerds, along with expert faculty Dr. Prateeti Khazanie, of the University of Colorado, discuss a question related to managing a patient with stage D (advanced) heart failure by referencing Section 8.3 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. The question is as follows:

You are taking care of a 34-year-old man with chronic systolic heart failure from NICM with LVEF 20% s/p CRT-D. The patient was admitted 1 week prior with acute decompensated heart failure. Despite intravenous diuretics the patient developed acute kidney injury, and ultimately placed on intravenous inotropes on which he now seems dependent. He has been following up with an advanced heart failure specialist as an outpatient and has been undergoing evaluation for heart transplantation, which was subsequently completed in the hospital.

His exam is notable for an elevated JVP, a III/VI holosystolic murmur, and warm extremities with bilateral 1+ edema. His most recent TTE shows LVEF 20%, moderate MR, moderate-severe TR and estimated RVSP 34 mmHg. His most recent laboratory data shows Na 131 mmol/L, Cr 1.2 mg/dL, and lactate 1.6 mmol/L. Pulmonary artery catheter shows RA 7 mmHg, PA 36/15 mmHg, PCWP 12 mmHg, CI 2.4 L/min/m2 and SVR 1150 dynes*sec/cm5.

The patient was presented at transplant selection committee and approved for listing for orthotopic heart transplant. What is the most appropriate next step in the management of this patient?

A Refer patient for transcatheter edge-to-edge repair for MR
B Continue IV inotropes as a bridge-to-transplant
C Refer patient for tricuspid valve replacement
D Initiate 1.5L fluid restriction

The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.


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