The CardioNerds and Dr. Michelle Kittleson Discuss the Appropriate Next Step in HF Management

By CardioNerds - Last Updated: November 16, 2023

The CardioNerds correspondents Drs. Chelsea Amo-Tweneboah and Teodora Donisan are joined by expert faculty Dr. Michelle Kittleson to discuss the following question, which references Section 7.8 of the ACC/AHA/HFSA Guideline for the Management of Heart Failure.

A 69-year-old man was referred to the cardiology clinic after being found to have a reduced left ventricular ejection fraction (LVEF) and left ventricular hypertrophy. For the last several months he has experienced progressively worsening fatigue and shortness of breath while climbing the stairs. He has a history of bilateral carpal tunnel syndrome and chronic low back pain. He takes no medications.

On exam, his heart rate is 82 beats per minute, blood pressure is 86/60 mmHg, oxygen saturation is 97% breathing ambient air, and body mass index is 29 kg/m2.

The patient has a regular heart rate and rhythm, with normal S1 and S2, bibasilar pulmonary rales, and 1+ pitting edema in both legs. Electrocardiogram (EKG) shows normal sinus rhythm with a first-degree AV delay and low voltages. Transthoracic EKG shows a moderately depressed LVEF of 35% to 39%, severe concentric hypertrophy with a left ventricular posterior wall thickness of 1.5 cm, and strain imaging showing globally reduced longitudinal strain with apical sparring. There is also biatrial enlargement and a small pericardial effusion.

A pharmacologic nuclear stress test did not reveal any perfusion defects. A gammopathy panel (including SPEP, UPEP, serum and urine immunofixation studies, and serum free light chains) is also unrevealing. A 99mTc-pyrophosphate scan was positive with grade 3 uptake.

In addition to starting diuretics, what is the most appropriate next step for managing this patient?

A Start metoprolol succinate.
B Start sacubitril/valsartan.
C Perform genetic sequencing of the TTR gene.
D Perform endomyocardial biopsy.

*The answer is provided at 4:58 of the podcast.

The Decipher the Guidelines: 2022 ACC/AHA/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 the education spectrum from college through advanced fellowship—under the leadership of The CardioNerds cofounders, Drs. Amit Goyal and Dan Ambinder, with mentorship from Drs. Anu Lala, Robert Mentz, and Nancy Sweitzer. We thank Drs. Judy Bezanson and Elliott Antman for their tremendous guidance.

This podcast originally appeared on The CardioNerds.

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