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Contemporary Medical Options for Treating Patients With Heart Failure

Case study: A 72-year-old woman presented with shortness of breath. Three months earlier, she had begun to notice dyspnea on exertion. This dyspnea progressed to the point that she noted dyspnea at rest in the 24 hours before presentation. She had a history of long-standing mild hypertension, treated with a calcium-channel antagonist, and type 2 diabetes. She denied chest pain, lightheadedness, and abdominal or ankle swelling, although she believed that she had gained between 5 and 10 pounds in recent weeks. On examination, she had a blood pressure of 150/90 mm Hg, a regular pulse at a rate of 90 min−1, jugular venous pressure of about 8 cm water, faint bibasilar crackles, a prominent and displaced apical impulse, and a summation gallop, with no murmurs, no organomegaly, or ascites, but with 1+ ankle edema. Laboratory findings were notable for a creatinine level of 2.0 mg/dL, a random blood sugar level of 220 mg/dL, and proteinuria (protein:creatinine=400 mg/g). Her ECG showed sinus rhythm, left atrial enlargement, left ventricular hypertrophy (LVH), Q waves in the inferior leads, and inferolateral ST- and T-wave changes. The ECG findings were unchanged, except for a heart rate that had increased from a tracing taken 6 months earlier. Her chest x-ray showed a mildly enlarged cardiac silhouette and questionable evidence of pulmonary venous congestion. An echocardiogram showed a moderately dilated left ventricle with increased wall thickness, inferobasilar akinesis, and an ejection fraction estimated between 30% and 35%.

Our patient presented with signs and symptoms of heart failure. Her age was slightly below the average of patients hospitalized with heart failure.1 She manifested each of the 3 principal factors linked to increased risk of developing heart failure, which are hypertension, ischemic heart disease, and diabetes.2

As we begin to treat our patient, we should …